Behavioral Health Nurse - Managed Care

Position is On-Site

The Behavioral Health Nurse – Managed Care i s responsible for coordinating, monitoring, and delivering behavioral health services within a managed care environment. This role involves working closely with patients, providers, and interdisciplinary teams to assess behavioral health needs, develop individualized care plans, and ensure cost-effective, quality care in accordance with regulatory guidelines and organizational policies.

Key Responsibilities:

• Conduct comprehensive assessments of members’ behavioral and mental health status, including psychosocial and medical needs.
• Develop and implement individualized care plans, with an emphasis on behavioral health and comorbid conditions.
• Monitor treatment progress, adherence, and outcomes, coordinating adjustments with providers as necessary.
• Collaborate with psychiatrists, primary care providers, therapists, social workers, and community resources.
• Authorize services and coordinate referrals based on clinical guidelines and insurance coverage.
• Provide telephonic and/or in-person case management and member education regarding conditions, medications, and treatment options.
• Ensure services are cost-effective and meet quality standards, consistent with managed care requirements and clinical best practices.
• Maintain accurate and timely documentation in electronic health records and care management platforms.
• Identify and intervene in high-risk cases to reduce emergency department visits and hospital admissions.
• Participate in interdisciplinary case rounds, quality improvement initiatives, and utilization review processes.
• Support members during transitions of care, including discharge planning and follow-up coordination.
• Stay informed on behavioral health regulations, evidence-based practices, and managed care policies.
• Presents case for patients not meeting criteria for medical necessity for the requested level of care/patient status to the Medical Director.
• Proactively identifies and resolves delays and obstacles for safe discharge. Seeks consultation from appropriate disciplines/departments to expedite care and facilitate safe discharge.
• Collaborates with family, health care team, payors, and providers to achieve appropriate resource management to implement safe discharge plan of care established by health care team and family.
• Assists in identifying and reporting variances in utilization of resources, avoidable days/denials. Works in collaboration with Appeals Management/Medical Director in the appeals process.
• Responsible for the appropriate use of software and applications and enters case management information accurately and in a timely manner.
• Adheres to Medicare and Medicaid regulatory guidelines as it pertains to patient admission/safe discharge.
• Participates in utilization management initiatives/opportunities for improvement through departmental committee assignments.

Qualifications:
Required:

• Current and unrestricted RM license in Florida
• Minimum 2-3 years of clinical nursing experience, including behavioral/mental health
• Experience in a managed care, case management, or utilization review setting
• Strong understanding of behavioral health diagnoses, treatments, and psychotropic medications
• Knowledge of Medicaid, Medicare, and/or commercial insurance policies
• Demonstrates commitment to the Partners-in-Caring process and the behavioral expectations in all interactions and in performing all job duties.
• Able to maintain confidentiality of sensitive information.

Preferred:

• Bachelor’s or master’s degree in nursing (BSN/MSN)
• Certified Case Manager (CCM) or similar certification
• Fluent in Spanish preferred.

Skills and Competencies:

• Excellent communication and interpersonal skills
• Strong critical thinking and clinical judgment
• Ability to manage multiple cases and prioritize tasks
• Proficiency with EHRs, care management software, and Microsoft Office Suite
• Compassionate, patient-centered approach
• Understanding of cultural competence and trauma-informed care

Working Conditions:

• On site in office in Coral Gables
• Standard business hours with occasional after-hours needs for urgent cases

Note: This description indicates, in general terms, the type and level of work performed and responsibilities held by the team member(s). Duties described are not to be interpreted as being all-inclusive or specific to any individual team member.

No Third Party Agencies or Submissions Will Be Accepted.

Our company is committed to creating a diverse environment. All qualified applicants will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, disability, age, or veteran status. DFWP

Opportunities posted here do not create any implied or express employment contract between you and our company / our clients and can be changed at our discretion and / or the discretion of our clients. Any and all information may change without notice. We reserve the right to solely determine applicant suitability. By your submission you agree to all terms herein.