Blue Shield of CA
Behavioral Health Utilization Mgmt Clinician, Senior
Blue Shield of CA, Long Beach, California, us, 90899
Your Role
The Behavioral Health Utilization Management team performs prospective & concurrent utilization reviews and first-level determinations for members using BSC evidence-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 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, positive attitude, and high level of initiative Ability to identify problems and work towards problem resolution independently, seeking guidance as needed
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The Behavioral Health Utilization Management team performs prospective & concurrent utilization reviews and first-level determinations for members using BSC evidence-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 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, positive attitude, and high level of initiative Ability to identify problems and work towards problem resolution independently, seeking guidance as needed
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