Behavioral Health Utilization Management Clinician, Consultant (Lead)

Blue Shield of CA; Cameron Park (CA); On-site; USD 80,000 - 120,000; Full time

Job summary

A leading healthcare organization seeks a Behavioral Health Utilization Management Consultant (Lead) to oversee clinical reviews and support operations. The ideal candidate will have extensive experience in behavioral health management, strong analytical skills, and a current California license. This role offers an opportunity to lead a team and make impactful decisions in mental health care.

Qualifications

• At least seven (7) years of experience in a healthcare-related field.
• Five (5) years conducting Behavioral Health Utilization Management.
• Experience in a lead role or equivalent leadership training preferred.

Responsibilities

• Support clinicians with daily operations and provide coaching.
• Serve as the subject matter expert during clinical reviews.
• Conduct utilization reviews for mental health and substance use authorization requests.

Skills

Analytical skills

Communication skills

Organizational skills

Interpersonal skills

Time management

Education

Current unrestricted CA license (LCSW, LMFT, LPCC, PhD/PsyD, or RN)

Advanced degree in a relevant field

Tools

Microsoft Excel

Microsoft Outlook

Microsoft Word

Microsoft PowerPoint

Job description

Your Role

The Behavioral Health (BH) Utilization Management (UM) team performs prospective, concurrent, and retrospective utilization reviews, along with first-level determinations for members. They utilize BSC evidence-based guidelines, policies, and nationally recognized clinical criteria across multiple lines of business. The Behavioral Health Utilization Management, Consultant (Lead), reports to the Manager of Behavioral Health Utilization Management (BH UM). In this role, you will support clinicians with daily operations, provide coaching, and serve as the subject matter expert for the BH UM team during clinical reviews of mental health and substance use authorization requests at various levels of care for medical necessity.

Your Knowledge and Experience

• Current unrestricted CA license (LCSW, LMFT, LPCC, PhD/PsyD, or RN with Behavioral Health experience) required.
• Advanced degree in a relevant field is preferred.
• At least seven (7) years of experience in a healthcare-related field.
• Experience in a lead role or equivalent leadership training is preferred.
• Five (5) years conducting Behavioral Health Utilization Management for a health insurance plan or managed care environment is preferred.
• Deep knowledge of Behavioral Health Utilization Management, including the ability to interpret admission and continued stay clinical criteria against nonprofit association guidelines.
• Familiarity with medical terminology, diagnostic terms, and treatment modalities, including the ability to comprehend psychiatric evaluations, clinical notes, and lab results.
• Proficiency with Microsoft Excel, Outlook, Word, PowerPoint, and the ability to learn and utilize multiple systems/databases.
• Excellent analytical, communication, written, time management, and organizational skills.
• Outstanding interpersonal, organizational, and communication skills, with a positive attitude and high initiative.
• Ability to identify problems and work towards resolution independently, seeking guidance as needed.