Clinician II

Horizon Connect @ Wall BCBSNJ

. Assess patients' behavioral health clinical needs against established guidelines and standards to determine medically appropriate level of care and length of stay.

Posted 10/7/2026full-timeRemote • New Jersey • United StatesJuniorMid-Level💰 $79,100 - $105,945 per yearWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in behavioral health clinical assessment, care coordination, and case management, with a strong focus on applying established guidelines and advocating for patient needs. Proficient in utilizing clinical criteria and managing care across various settings while ensuring compliance and quality improvement.

Highest-signal resume keywords

Behavioral Health Clinical ExperienceUtilization Management PrinciplesMilliman Care Guidelines (MCG)American Association of Addiction Medicine (ASAM) CriteriaActive Unrestricted NJ LCSW, LMFT, LPC, LBA or RN License

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Behavioral Health AssessmentCare Plan DevelopmentMotivational InterviewingQuality Improvement ProgramsCase Management Principles

Soft Skills

Communication with Multidisciplinary TeamsAdvocacy for Members and FamiliesMentoring and Training

Tools & Technologies

MS Office ProductsLotus NotesWindows Based Software

Certifications & Qualifications

CCM CertificationActive Unrestricted NJ LCSW, LMFT, LPC, LBA or RN License

Industry Keywords

Managed Care SettingHealth Insurance IndustryBehavioral HealthCare CoordinationTransitional Care

About the role

Key responsibilities & impact

Assess patients' behavioral health clinical needs against established guidelines and standards to determine medically appropriate level of care and length of stay.
Evaluate the necessity, appropriateness, and efficiency of behavioral health medical services and procedures.
Develop, coordinate, and assist with implementation of individualized member care plans and identify barriers to self-management and wellness.
Apply Milliman Care Guidelines (MCG) and American Association of Addiction Medicine (ASAM) criteria.
Monitor and coordinate out-of-network and out-of-area services and negotiate fees when appropriate.
Coordinate with patients, families, physicians, hospitals, and external customers regarding care appropriateness from diagnosis through outcome.
Coordinate high-quality, cost-effective care across the continuum, including transitional care.
Monitor behavioral health care activities and outcomes for appropriateness and effectiveness.
Advocate for members and families across care settings.
Encourage member participation and compliance in behavioral health case/disease management programs.
Document accurately and comprehensively according to practice standards and organizational policies.
Communicate with multidisciplinary teams telephonically and/or in person.
Evaluate care, analyze variances, and participate in quality improvement programs.
Mentor and train new BH Clinicians and other staff.
Serve as an escalation point for complex cases and issues.
Coordinate clinical process improvements with the team supervisor.
Work independently on special projects and complex cases.
Recommend workflow and process improvements.
Execute UAT test cases end to end.
Work one holiday shift per year.
For Navigation roles, facilitate responses to care gaps and high-risk members, collaborate with providers, and present clinical cases during external audits.
For BH Clinical Advocate roles, conduct member outreach, apply clinical expertise, use Motivational Interviewing, explain ASO benefits, and educate members to navigate the healthcare system.
Work an 8- or 10-hour Monday–Friday schedule with operating hours varying from 8AM–8PM EST.
Travel to office locations as required for BH Clinical Advocate roles.

Requirements

What you’ll need

High School Diploma/GED required.
Bachelor degree in a behavioral health related field or Nursing degree preferred or relevant experience in lieu of degree.
Prefers a masters in a behavioral health related field or Nursing degree.
Requires a minimum of 2 years behavioral health clinical experience.
Requires 1 year behavioral health experience in a managed care setting or health insurance industry.
Active Unrestricted NJ LCSW, LMFT, LPC, LBA or RN License Required.
CCM Certification preferred for BH Clinical Advocate roles.
Proficiency in the use of personal computers and supporting software in a Windows based environment, including MS Office products (Word, Excel, PowerPoint) and Lotus Notes preferred.
Knowledge in the use of intranet and internet applications preferred.
Working knowledge of case/care management principles preferred.
Working knowledge of principles of utilization management preferred.
Basic knowledge of health care contracts and benefit eligibility requirements preferred.
Knowledge of hospital structures and payment systems preferred.
Bi-lingual proficiency preferred for BH Clinical Advocate roles.
For field based positions, travel required 100%.

Benefits

Comp & perks

Comprehensive health benefits (Medical/Dental/Vision)
Retirement Plans
Generous PTO
Incentive Plans
Wellness Programs
Paid Volunteer Time Off
Tuition Reimbursement