Behavioral Health Utilization Mgmt Clinician, Senior

Behavioral Health Utilization Management Clinician, SeniorThe 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. 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.Our leadership model is about developing great leaders at all levels and creating opportunities for our people to grow – personally, professionally, and financially. We are looking for leaders that are energized by creative and critical thinking, building and sustaining high-performing teams, getting results the right way, and fostering continuous learning.ResponsibilitiesIn 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 a specific line of business such as Medicare as neededGather 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 determinationProvide information to facilities and providers regarding community treatment resources, mental health care management programs, company policies and procedures, and medical necessity criteriaWork 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 ManagerRecognize 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 teamSupport team through consistent and successful caseload management and workload to achieve team goals, regulatory timelines, and accreditation standardsQualificationsIn this role, you will need:Current unrestricted CA license (LCSW, LMFT, LPCC, PhD/PsyD or RN with Behavioral Health experience) requiredRN requires an Associates degree or Masters degree in relevant field for non- RN licensure5 years of prior relevant experience managed care environment or clinical settingStrong 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 guidelinesFamiliarity with medical terminology, diagnostic terms, and treatment modalities including ability to comprehend psychiatric evaluations, clinical notes, and lab resultsProficient with Microsoft Excel, Outlook, Word, Power Point, and the ability to learn and utilize multiple systems/databasesExcellent analytical, communication skills, written skills, time management, and organizational skillsPossess outstanding interpersonal, organizational, and communication skills, positive attitude, and high level of initiativeAbility to identify problems and work towards problem resolution independently, seeking guidance as neededHybrid Virtual WorkThis role allows employees to work virtually full-time, however employees will be expected to come to the office based on business need.About UsAbout Blue Shield of CaliforniaAs of January 2025, Blue Shield of California became a subsidiary of Ascendiun. Ascendiun is a nonprofit corporate entity that is the parent to a family of organizations including Blue Shield of California and its subsidiary, Blue Shield of California Promise Health Plan; Altais, a clinical services company; and Stellarus, a company designed to scale healthcare solutions. Together, these organizations are referred to as the Ascendiun Family of Companies.At Blue Shield of California, our mission is to create a healthcare system worthy of our family and friends and sustainably affordable. We are transforming health care in a way that genuinely serves our nonprofit mission by lowering costs, improving quality, and enhancing the member and physician experience.To achieve our mission, we foster an environment where all employees can thrive and contribute fully to address the needs of the various communities we serve. We are committed to creating and maintaining a supportive workplace that upholds our values and advances our goals.Blue Shield is a U.S. News Best Company to work for, a Deloitte U.S. Best Managed Company and a Top 100 Inspiring Workplace. We were recognized by Fair360 as a Top Regional Company, and one of the 50 most community-minded companies in the United States by Points of Light. Here at Blue Shield, we strive to make a positive change across our industry and communities – join us!Our Values:Honest. We hold ourselves to the highest ethical and integrity standards. We build trust by doing what we say we're going to do and by acknowledging and correcting where we fall short.Human. We strive to listen and communicate effectively, showing empathy by understanding others' perspectives.Courageous. We stand up for what we believe in and are committed to the hard work necessary to achieve our ambitious goals.Our Workplace ModelWe believe in fostering a workplace environment that balances purposeful in-person collaboration with flexibility - providing clear expectations while respecting the diverse needs of our workforce. Our workplace model is designed around intentional in-person interaction, collaboration, connection, creativity and flexibility:For most teams, this means coming into the office two days per week.Employees living more than 50 miles from an office location, out of state employees, and employees in certain member-facing roles should work with their manager to determine in-office time based on business need.For employees with medical conditions that may impact their ability to work in-office, we are committed to engaging in an interactive process and providing reasonable accommodations to ensure their work environment is conducive to their success and well-being.The Company reserves the right to require more presence in the office based on business needs, and requirements are subject to change with periodic reviews.Physical Requirements:Office Environment - roles involving part to full time schedule in Office Environment. Based in our physical offices and work from home office/deskwork - Activity level: Sedentary, frequency most of work day.Please click here for further physical requirement detail.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 regards 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.Job InfoJob Identification 20261736Job Category Healthcare Services and OperationsPosting Date 09/10/2026, 02:37 PMJob Schedule Full timeLocations San Diego - Camino Del RioPay Range for California $90860.00 to $136290.00Pay Range for Bay Area $102424.00 to $153636.00Note Please note that this range represents the pay range for this and many other positions at Blue Shield that fall into this pay grade. Blue Shield salaries are based on a variety of factors, including the candidate experience, location (California, Bay Area, or outside California), and current employee salaries for similar roles.Role can be filled by a candidate requiring sponsorship No