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PLADS BehavHealth Clinician Rev

The Company:  Aflac Columbus
The Location: 

Remote, US Orlando, FL, US, 32801

The Division:  PLADS
Job Id:  2030

Job Summary

The Behavioral Health Clinical Case Manager provides clinical co-management activities on STD that have a primary disabling behavioral health diagnosis. The Behavioral Health Clinician Reviewer also serves as a behavioral health resource and consultant to LTD and Leave Coordinators as well as clinical case managers reviewing dually diagnosed claims where expertise is needed to assess the behavioral health components of disability claims related to work capacity. Effective and timely decisions and claims handling, while providing a positive customer experience.


Principal Duties & Responsibilities

Serves as Clinical co-manager on behavioral health claims from day 1 of STD claims and provides activities requiring clinical expertise including, but not limited to, performing provider interviews, analyzing clinical information submitted, and negotiating return to work plans with employee, treating provider, and employer if applicable


Reviews and evaluates disability claims to determine level of functioning based on knowledge of behavioral health conditions and knowledge of the employer and the employee's job requirements, as well as the plan's definition of disability


Investigates and resolves inconsistencies in the level of cognitive, emotional, or behavioral functioning


Coordinates a strategy to determine true level of functional capacity utilizing direct contact with the treating provider and/or utilizing internal clinical resources (e.g. Peer-to-Peer Reviews, internal impairment guides, round table reviews, etc.)


Reviews claims from a behavioral health perspective to determine if clinical evidence supports preclusion from work or need for accommodation and/or restrictions based on vocational demands per the applicable definition of disability


Documents impairment, functional status, and assessment to include behavioral health, contractual, and vocational information


Acts as behavioral health consultant to the Appeals Unit


Acts as resource for claim and clinical staff when handling claimants noted to be threatening harm to themselves or others


Facilitates referrals to collateral internal and external services, e.g. EAP, disease management programs, Advocacy, etc. as applicable


Monitors response to care and advocates for optimal care if applicable


Coordinates and monitors quality of behavioral health IME's


Coordinates internal physician consultant referrals by using supporting clinical resources and vocational resources


Identifies barriers for employees to return to work as well as identifying appropriate (optimal) health care, rehabilitation, and work to facilitate an appropriate and timely return to work


Communicates effectively with case managers, employers, employees, and health care providers


Strategizes with claimant, treating providers, and employer on possible accommodations or restriction utilization to facilitate return to work


Manages daily relations with assigned accounts and key contacts


Per account requirements and upper management request, visits clients for new account implementation and maintenance of existing accounts


Attends and/or presents clinical lectures designed to educate claim staff as requested.


Independently collates and analyzes data using pre-determined tools, methods and formats and makes recommendations to support the department’s timely resolution of claims


Anticipates, recognizes, and responds timely to needs of customers to ensure customer satisfaction


Supports implementation of customer initiatives to drive best outcomes


Reviews assigned customer cases, prioritizes workload, and interprets established policies, applying discretion within authority limits to resolve customer issues


Provides status updates on co-management plans to ensure clear communications and transparency


Resolves technical problems by referring to policies, procedures, specifications to ensure accuracy and operational consistency


Collects data and prepares clinical reviews including commentary and an analysis to facilitate decision making


Provides detailed procedural advice to internal clients to ensure that internal standards and/or procedures are adhered to related to clinical co-management


Inputs relevant data into established systems accurately to allow for data analysis


Analyzes data using pre-determined tools, methods, and formats; makes recommendations to support the department's timely management of behavioral health claims


Performs additional Job duties as requested by manager


Education & Experience Required

Bachelor's Degree In healthcare or a related field


Master's Degree In Behavioral Health area or in related field, e.g., MSW, MA or MS in counseling (Preferred)


Current license and or License eligible


2 or more years of experience in disability management industry managing claims


CDMS or CCM designations


Utilization Review Experience and/or experience using specific behavioral health criteria or protocols


Or an equivalent combination of education and experience.


Job Knowledge & Skills

• Psychiatric experience/knowledge


• Solid investigative and analytical skills


• Solid customer service skills


• Solid written and oral communication skills


• Solid organizational and time management skills


• Ability to analyze behavioral health records in the context of functional capacity


• Work in team environment


• Business Travel, as required


• Extended Hours during Peak Periods, as required


• Maintain a Valid Driver's License, as required


• Pass Applicable Exam/Licensing, and maintain active license as required


• Regular Predictable Attendance


• Model behaviors that demonstrate commitment to corporate values


• Provide input into performance management discussions of project team members, if requested by manager


• Educate team members and business partners on area of clinical expertise


• Provide guidance and support for team members


• Manage own personal development and encourage others to do the same which includes promoting a healthy and positive work environment


• Seeks and maintains current profession credentials



Acting with Integrity - Clearly states goals and beliefs; lets people know his/her true intentions; does what he she said they would do; follows through on commitments


Communicating Effectively - Expresses ideas and information in a clear and concise manner; tailors message to fit the interests and needs of the audience; delivers information in a manner that is interesting and compelling to the listener


Pursuing Self-Development - Demonstrates ambition and desire to move forward in his/her career; engages others in discussions about career development; seeks feedback on ways to increase his/her performance; takes advantage of opportunities to build new skills and capabilities


Serving Customers - Builds strong relationships with customers; stays aware of customer needs, concerns and satisfaction; responds promptly to customer questions and requests; effectively manages


Supporting Change - Enthusiastically participates in new change initiatives and programs; focuses on reasons why changes will work and how they will be beneficial


Supporting Organizational Goals - Actively supports organizational goals and values; demonstrates enthusiasm toward the company's goals and mission; aligns actions around organizational goals


Working with Diverse Populations - Shows respect for the beliefs and traditions of others; encourages and promotes practices that support cultural diversity; discourages behaviors or practices that may be perceived as unfair, biased, or critical toward people with certain background

Nearest Major Market: Eugene