Behavioral Health Utilization Mgmt Clinician, Senior

Blue Shield of CA; San Diego (CA); Hybrid; USD 90,000 - 120,000; Full time

Job summary

Blue Shield of California seeks a Senior Behavioral Health Utilization Management Clinician to perform prospective and concurrent reviews, applying evidence-based guidelines across multiple lines of business.

You will review mental health and substance use requests for medical necessity, coding accuracy, and policy compliance, reporting to the BH UM Manager. Hybrid work with office-based needs may arise based on business requirements.

Qualifications

• 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 in 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.

Responsibilities

• Conduct clinical review of mental health and substance use authorization requests at various levels of care for medical necessity.
• Ensure coding accuracy, medical policy compliance, and contract compliance.
• Contribute to the BH UM team by applying evidence-based criteria and guidelines.
• Collaborate with cross-functional teams to support member care and outcomes.

Skills

CA License

Clinical review experience

MCG guidelines

Medical terminology

Excel/Office proficiency

Communication skills

Problem solving

Education

Masters or Doctorate in field

RN with BH experience (Assoc or higher)

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.