Clinical Case Manager

Jobtailor; Las Vegas (NV); Hybrid; USD 90,000 - 120,000; Full time

Job summary

Jobtailor in Nevada seeks an experienced clinical resource to support CHWs within a Medicaid-focused care team. You will provide real-time case consultation, behavioral health assessments, and escalation when needed, while aligning with state and plan guidelines.

You will own TOC queue audits, mentor CHWs, coordinate with PCPs and care managers, ensure compliant documentation, and identify opportunities for compliant direct billing of licensed interventions.

Qualifications

• Active, unrestricted Nevada license in RN/LPN/LCSW/LMHC.
• Degree appropriate to licensure (ASN/BSN, MSW, etc.).
• 3+ years of post-licensure clinical or case management experience.

Responsibilities

• Serve as embedded clinical resource for CHWs.
• Provide real-time case consultation and clinical guidance to CHWs.
• Own daily clinical audit of the TOC queue and triage referrals.
• Identify members whose needs exceed CHW scope and coordinate hand-offs.
• Lead monthly joint Level 1/2 case conferences with health plan leadership.
• Coach CHWs on engagement skills and escalation of risk indicators.
• Oversee Medicaid claims cycle, including pre-submission reviews and denial management.
• Identify and execute direct-billing opportunities for licensed behavioral health interventions.
• Develop and reinforce team workflows and clinical protocols with leadership.
• Conduct biopsychosocial assessments to identify needs, strengths, and risks.
• Provide brief, evidence-based clinical interventions and warm hand-offs to treatment.
• Contribute to care plans as part of the interdisciplinary team.
• Apply trauma-informed and culturally responsive practice across Medicaid population.
• Serve as escalation point for behavioral health or crisis concerns.
• Coordinate crisis response and linkage to emergency services.
• Support CHWs in difficult field situations and through debriefing.
• Connect members to behavioral health services and community resources.
• Build relationships with community-based organizations and providers.

Skills

Clinical guidance

Case management

Behavioral health interventions

Mentorship

Telehealth readiness

Education

ASN/BSN

MSW

Master's in counseling

Job description

Responsibilities

• Serve as the embedded clinical resource for a team of CHWs
• Provide real-time case consultation, clinical guidance, and side‑by‑side assistance to CHWs on complex member situations.
• Own the daily clinical audit of the Transitions of Care (TOC) queue, utilizing health plan guidelines to appropriately triage complex Level 2 cases and route clean Level 1 referrals to the CHW team.
• Identify members whose needs exceed the CHW scope and step in directly or coordinate the appropriate clinical hand‑off.
• Lead and represent the organization in monthly joint Level 1 and Level 2 case conferences with health plan clinical leadership.
• Coach and mentor CHWs to strengthen engagement skills, recognition of behavioral health and risk indicators, and appropriate escalation.
• Oversee the end‑to‑end Medicaid claims cycle for the clinical team, including pre‑submission documentation reviews, code utilization tracking, and denial management.
• Identify and execute direct‑billing opportunities for licensed behavioral health interventions and assessments allowable under Nevada Medicaid.
• Help develop and reinforce team workflows, clinical protocols, and best practices in partnership with leadership.
• Conduct biopsychosocial and behavioral health assessments to identify member needs, strengths, and risks.
• Provide brief, evidence‑based clinical intervention (such as motivational interviewing and solution‑focused techniques) and warm hand‑offs to ongoing behavioral health treatment.
• Contribute clinical expertise to individualized care plans as part of the interdisciplinary care team (ICT).
• Apply trauma‑informed and culturally responsive practice across a diverse, predominantly Medicaid population.
• Serve as the team's escalation point for members presenting with behavioral health, safety, or crisis concerns.
• Conduct risk assessment and coordinate appropriate crisis response, follow‑up, and linkage to emergency or stabilization services.
• Support CHWs through difficult situations in the field and debrief afterward.
• Partner with CHWs to connect members to behavioral health services, community resources, and supports addressing social determinants of health, including housing, food, transportation, employment, and benefits.
• Build and maintain relationships with community‑based organizations and behavioral health providers across the assigned territory.
• Coordinate with PCPs, care managers, and health‑plan partners to close gaps in care.
• Maintain timely, accurate clinical documentation in the care management platform.
• Ensure work meets Medicaid, state, NCQA, and organizational clinical and privacy (HIPAA) standards.
• Contribute to quality initiatives and outcome tracking for the team.
• Other duties as assigned

Requirements

• Active, unrestricted Nevada license in one of the following: Registered Nurse (RN), Licensed Practical Nurse (LPN), Licensed Clinical Social Worker (LCSW), or Licensed Mental Health Counselor (LMHC).
• Degree appropriate to your licensure (for example, ASN or BSN for nursing, MSW for LCSW, master's in counseling for LMHC).
• Prior case management, hospital, discharge planning, or care coordination experience strongly preferred.
• Case Management Certification (for example, CCM) is preferred.
• 3+ years of post‑licensure clinical or case management experience, including assessment and, where applicable to your scope, crisis intervention.
• Experience working with Nevada Medicaid, underserved, or community‑based populations.
• Demonstrated experience with Medicaid documentation, billing workflows, or CPT/HCPCS coding within an integrated care or care management setting is a plus.
• Strong knowledge of social determinants of health and community resource navigation.
• Ability to work effectively alongside CHWs and interdisciplinary teams as a non‑supervisory clinical resource.
• Comfort with community/field‑based work and telehealth; valid driver's license and reliable transportation if field travel is required.
• Managed care, care management, or integrated behavioral health experience preferred.
• Familiarity with local community resources and the regional behavioral health landscape.

Core Competencies

Demonstrates expertise in clinical guidance, case management, and behavioral health interventions, with a strong focus on Medicaid regulations and community resource navigation. Proven ability to mentor and support community health workers while ensuring compliance with clinical standards and best practices.