Behavioral Health Utilization Mgmt Clinician, Senior

Blue Shield of CA; Springfield Meadows (CA); Hybrid; USD 120,000 - 150,000; Full time

Job summary

Blue Shield of California is seeking a Senior Behavioral Health Utilization Management Clinician to conduct clinical reviews of mental health and substance use authorization requests, ensuring medical necessity and policy compliance. The role reports to the BH UM Manager and supports high-performing teams.

The position is hybrid with potential in-office requirements based on business need. Requires a current CA license and 5 years of relevant experience in managed care or clinical settings.

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, coding accuracy, medical policy compliance and contract compliance.
• Interpret and apply admission and continued stay criteria from standardized clinical guidelines.
• Collaborate with BH UM leadership to support high-quality utilization management.

Skills

Clinical review

Analytical skills

Communication skills

Time management

Organizational skills

Education

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

Associates or Masters degree for RN licensure

Tools

Microsoft Excel

Outlook

Word

PowerPoint

Multiple systems/databases

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.