Behavioral Health Utilization Management Clinician, Senior

Blue Shield of CA; California, Cameron Park (MO, CA); On-site; USD 80,000 - 110,000; Full time

Job summary

A leading healthcare provider seeks a Senior Behavioral Health Utilization Management Clinician to conduct clinical reviews for mental health and substance use requests. The role requires a current CA license and extensive experience in behavioral health management, ensuring compliance with clinical guidelines and policies. Ideal candidates will possess strong analytical and communication skills, and a commitment to high-quality patient care.

Qualifications

• 5+ years in healthcare, 3+ years in Behavioral Health Utilization Management.
• Strong understanding of clinical criteria sets and medical terminology.
• Ability to work independently and resolve problems.

Responsibilities

• Conduct clinical reviews of mental health and substance use authorization requests.
• Ensure compliance with medical necessity and coding accuracy.
• Apply and interpret admission and continued stay criteria.

Skills

Analytical skills

Communication

Organizational skills

Interpersonal skills

Education

Advanced degree in relevant field

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

Tools

Microsoft Excel

Microsoft Outlook

Microsoft Word

Microsoft PowerPoint

Job description

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 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.

Your Knowledge and Experience

• Current unrestricted CA license (LCSW, LMFT, LPCC, PhD/PsyD, or RN with Behavioral Health experience) required


• Advanced degree commensurate with the field is preferred


• Requires 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


• Strong understanding of Behavioral Health Utilization Management, including the ability to apply and interpret admission and continued stay criteria of multiple standardized clinical criteria sets, including but not limited to MCG guidelines, nonprofit association guidelines, and various Medicare guidelines


• Familiarity with medical terminology, diagnostic terms, and treatment modalities, including the ability to comprehend psychiatric evaluations, clinical notes, and lab results


• Proficient 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, a positive attitude, and a high level of initiative


• Ability to identify problems and work towards problem resolution independently, seeking guidance as needed