Join to apply for the Senior Behavioral Health Utilization Management Clinician role at Blue Shield of California .
The Behavioral Health Utilization Management team performs prospective & concurrent utilization reviews and first level determinations for members using BSC evidenced based guidelines, policies, and nationally recognized clinical criteria across multiple lines of business.
The Behavioral Health Utilization Management Clinician, Senior, will report to the Manager of Behavioral Health Utilization Management (BH UM). In this role, you will conduct clinical reviews of mental health and substance use authorization requests at various levels of care for medical necessity, coding accuracy, medical policy compliance, and contract compliance.
California license (LCSW, LMFT, LPCC, PhD/PsyD or RN with Behavioral Health experience) is required,
In this role, you will:
Perform prospective & concurrent utilization reviews and first level determination approvals for members admitted to facilities using BSC evidenced based guidelines, policies, and nationally recognized clinical criteria across lines of business or for specific lines such as Medicare as needed.
Gather clinical information and apply the appropriate clinical criteria/guideline, policy, procedure, and clinical judgment to render coverage determinations and recommendations along the continuum of care, including effective discharge planning at levels of care appropriate for the members' needs and acuity; prepare and present cases to Medical Director (MD) for oversight and necessity determination.
Provide information to facilities and providers regarding community treatment resources, mental health care management programs, company policies and procedures, and medical necessity criteria.
Work with multidisciplinary teams to support members using an integrated team-based approach, including Interdisciplinary Team Meetings and case consultations with Medical Director and/or Licensed Manager.
Recognize the members' right to self-determination related to the ethical principle of autonomy, including the members/family's right to make informed choices that may not promote the best outcomes, as determined by the healthcare team.
Support the team through consistent caseload management and workload to achieve team goals, regulatory timelines, and accreditation standards.
Qualifications
Current unrestricted CA license (LCSW, LMFT, LPCC, PhD/PsyD or RN with Behavioral Health experience) required.
Advanced degree in a related field is preferred.
At least five (5) years of prior experience in a healthcare-related field.
Three (3) years conducting Behavioral Health Utilization Management for a health insurance plan or managed care environment required.
Seniority level Mid-Senior level
Employment type Full-time
Job function Health Care Provider
Industries Hospitals and Health Care