Behavioral Health Utilization Reviewer

Bcbsla; United States; Remote; USD 70,000 - 100,000; Full time

Job summary

Louisiana Blue is seeking a Behavioral Health Utilization Reviewer to conduct clinical reviews of behavioral health service requests, claims, and appeals, applying InterQual criteria and collaborating with the Behavioral Health Medical Director. This role emphasizes timely, professional communication and adherence to policy.

Required qualifications include a bachelor's in nursing/healthcare or a master's in social work with Louisiana licensure (RN/LPN substitutions allowed), at least 3 years of

Qualifications

• Bachelor’s degree in nursing, healthcare, or a related field OR Master’s degree in social work, counseling, or behavioral health.
• RN license in Louisiana may replace Bachelor's degree; LPN license in Louisiana plus 2 years related experience may replace.
• At least 3 years of clinical or patient care experience in behavioral health.
• Must hold one of the licenses: LPC, PLPC, LCSW, LMFT, LMSW, LPN, or RN.
• Strong clinical assessment and critical thinking.
• Excellent communication and teamwork.
• Good understanding of behavioral health conditions and treatments.
• Able to work independently and follow policies.

Responsibilities

• Review pre-authorization requests, concurrent reviews, and retrospective claims for behavioral health services.
• Apply clinical guidelines to document medical necessity.
• Refer cases to Psychiatric Medical Director for secondary review.
• Review and support appeals in accordance with regulatory timelines.
• Interacts with BH care providers to discuss level of care and/or service decisions.
• Document clinical decisions and rationale in the utilization management system.
• Communicate determinations to providers and members via phone and written correspondence.
• Analyze BH member data to improve quality and appropriate utilization of services.
• Collaborate with internal departments including Case Management, Quality, and Provider Relations.
• Maintain compliance with state, federal, and accreditation requirements (CMS, NCQA, URAC).
• Participate in audits, training, and quality improvement initiatives.

Skills

Clinical assessment

Critical thinking

Communication

Teamwork

Independence

Education

Bachelor’s degree in nursing/healthcare, or Master’s in social work/counseling/behavioral health

RN license (Louisiana) or LPN with experience substitute for degree

Job description

We take great strides to ensure our employees have the resources to live well, be healthy, continue learning, develop skills, grow professionally and serve our local communities. We invite you to apply for a career with us.

Residency in or relocation to Louisiana is preferred for all positions.

Applicants must be authorized to work for Louisiana Blue in the United States without employer-sponsored immigration support. Louisiana Blue will not provide current or future employment-based immigration sponsorship or other immigration support for this opportunity, including H-1B, L-1, O-1, H-1B1, E-3, TN, or J-1 sponsorship or F-1 OPT/STEM OPT/CPT support. Applicants who would require such sponsorship or employer support during their employment should not pursue this opportunity.

POSITION PURPOSE

The Behavioral Health Utilization Reviewer is responsible for conducting clinical reviews of behavioral health service requests, claims, and appeals to confirm medical necessity and appropriateness of care. The reviewer applies evidence-based criteria including InterQual and/or medical policy and collaborates with theBehavioral Health Medical Director for complex cases and requests that do not meet criteria for approval. This role does not make adverse determinations based on medical necessity. This role also involves gathering information from and communicating decisions to providers and members in a clear, timely, and professional manner.

How You Contribute to the Company’s Mission In This Role

• Review pre-authorization requests, concurrent reviews, and retrospective claims for behavioral health services.
• Apply clinical guidelines (e.g., InterQual, medical policy) to document medical necessity.
• Refer cases that do not meet criteria to the Psychiatric Medical Director for secondary review.
• Review and support the appeals department in reviewing provider and member appeals in accordance with regulatory timelines.
• Interacts with BH care providers as necessary to discuss level of care and/or service decisions.
• Document clinical decisions and rationale in the utilization management system.
• Communicate determinations to providers and members via phone and written correspondence.
• Analyze BH member data to improve quality and appropriate utilization of services
• Collaborate with internal departments including Case Management, Quality, and Provider Relations.
• Maintain compliance with state, federal, and accreditation requirements (e.g., CMS, NCQA, URAC).
• Participate in audits, training, and quality improvement initiatives.

Required Qualifications

• Bachelor’s degree in nursing, healthcare, or a related field ORmaster’s degree in social work, counseling, or behavioral health
• RN license in Louisiana can replace the Bachelor’s Degree -OR-LPN license in Louisiana + 2 years of related experience can replace the Bachelor’s degree
• At least 3 years of clinical or patient care experience in behavioral health
• Must have one of the following licenses: LPC, PLPC, LCSW, LMFT, LMSW, LPN, or RN
• Strong clinical assessment and critical thinking
• Excellent communication and teamwork
• Good understanding of behavioral health conditions and treatments
• Able to work independently and follow policies

Preferred Qualifications

• Experience in a managed care or health insurance setting
• Familiarity with CPT codes and billing practices.
• Experience working with Medicare and Commercial populations
• Proficiency in electronic health records and case management systems

The Physical Demands described here are representative of those that must be met by an employee to successfully perform the Accountabilities and Essential Functions of the job. Reasonable accommodations may be made to enable an individual with disabilities to perform the essential functions

• Perform other job-related duties as assigned, within your scope of responsibilities.
• Job duties are performed in a normal and clean office environment with normal noise levels.
• Work is predominately done while standing or sitting.
• The ability to comprehend, document, calculate, visualize, and analyze are required.

An Equal Opportunity Employer

PLEASE USE A WEB BROWSER OTHER THAN INTERNET EXPLORER IF YOU ENCOUNTER ISSUES (CHROME, FIREFOX, SAFARI)

Additional Information

Please be sure to monitor your email frequently for communications you may receive during the recruiting process. Due to the high volume of applications we receive, only those most qualified will be contacted. To monitor the status of your application, please visit the “My Applications” section in the Candidate Home section of your Workday account.

In support of our mission to improve the health and lives of Louisianians, we encourage the good health of its employees and visitors. We want to ensure that our employees have a work environment that will optimize personal health and well-being. Due to the acknowledged hazards from exposure to environmental tobacco smoke, and in order to promote good health, our company properties are smoke and tobacco free.

We perform background and pre-employment drug screening after an offer has been extended and prior to hire for all positions. As part of this process records may be verified and information checked with agencies including but not limited to the Social Security Administration, criminal courts, federal, state, and county repositories of criminal records, Department of Motor Vehicles and credit bureaus. Pursuant with sec 1033 of the Violent Crime Control and Law Enforcement Act of 1994, individuals who have been convicted of a felony crime involving dishonesty or breach of trust are prohibited from working in the insurance industry unless they obtain written consent from their state insurance commissioner.

Additionally, we are a Drug Free Workplace. A pre-employment drug screen will be required and any offer is contingent upon satisfactory drug testing results.