Behavioral Health Utilization Mgmt Clinician, Senior

Blue Shield of CA; Oakland (CA); Hybrid; USD 120,000 - 160,000; Full time

Job summary

Blue Shield of CA is seeking a Senior Behavioral Health Utilization Management Clinician to conduct prospective and concurrent reviews for medical necessity, coding accuracy, and policy compliance. You will report to the BH UM Manager and review mental health and substance use authorizations across multiple lines of business.

Ideal candidates hold a CA behavioral health license and have 5+ years in managed care or clinical settings, with strong analytical and communication abilities.

Qualifications

• Current unrestricted CA license (LCSW, LMFT, LPCC, PhD/PsyD or RN with Behavioral Health experience) required.
• RN requires an Associate's or Master's degree in a relevant field for non-RN licensure.
• 5 years of prior relevant experience in managed care environments or clinical settings.
• Strong understanding of Behavioral Health Utilization Management and applicable clinical criteria.
• Familiarity with medical terminology, psychiatric evaluations, and lab results.
• Proficiency with Excel, Outlook, Word, PowerPoint and ability to learn multiple systems/databases.
• Excellent analytical, written and verbal communication, time management, and organizational skills.
• Strong interpersonal skills, initiative, and ability to identify and resolve problems.

Skills

Analytical skills

Communication skills

Written communication

Time management

Organizational skills

Interpersonal skills

Education

CA behavioral health license types

RN licensure with degree requirements

Tools

Microsoft Excel

Outlook

Word

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 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.

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.

Your Knowledge and Experience

• Current unrestricted CA license (LCSW, LMFT, LPCC, PhD/PsyD or RN with Behavioral Health experience) required
• RN requires an Associates degree or Masters degree in relevant field for non- RN licensure
• 5 years of prior relevant experience managed care environment or clinical setting
• 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
• 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 to the office based on business need.