Behavioral Health Utilization Mgmt Clinician, Experienced

Your Role 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 clinal 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 review of mental health and substance use authorization requests at various levels of care for medical necessity, coding accuracy, medical policy compliance and contract compliance. Responsibilities Perform prospective & concurrent utilization reviews and first level determination approvals for members admitted to facilities using BSC evidenced based guidelines, policies and nationally recognized clinal criteria across lines of business or for a specific line of business such as Medicare as needed Gather clinical information and apply the appropriate clinical criteria/guideline, policy, procedure and clinical judgment to render coverage determination/recommendation along the continuum of care facilitates including effective discharge planning at levels of care appropriate for the members needs and acuity; prepare and present cases to Medical Director (MD) for medical director 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 as it relates 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 team through consistent and successful 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 commensurate with field is preferred Requires at least three (3) years of prior experience in healthcare related field One (1) year conducting Behavioral Health Utilization Management for a health insurance plan or managed care environment required Strong understanding of Behavioral Health Utilization Management including ability to apply and interpret admission and continued stay criteria of multiple standardized clinical criteria including but not limited to MCG guidelines, nonprofit association guidelines, and various Medicare guidelines ASAM 3rd Edition, ASAM 4th Edition, LOCUS and CALOCUS are preferred certifications Familiarity with medical terminology, diagnostic terms, and treatment modalities including ability to comprehend psychiatric evaluations, clinical notes, and lab results Proficient with Microsoft Excel, Outlook, Word, Power Point, and the ability to learn and utilize multiple systems/databases Excellent analytical, communication skills, written skills, time management, and organizational skills Possess outstanding interpersonal, organizational, and communication skills, positive attitude, and high level of initiative Ability to identify problems and work towards problem resolution independently, seeking guidance as needed Hybrid Virtual Work This role allows employees to work virtually full‑time, however employees will be expected to come into the office based on business needs. Equal Employment Opportunity External hires must pass a background check/drug screen. Qualified applicants with arrest records and/or conviction records will be considered for employment in a manner consistent with Federal, State and local laws, including but not limited to the San Francisco Fair Chance Ordinance. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran status or disability status and any other classification protected by Federal, State and local laws. #J-18808-Ljbffr Blue Shield of California