Behavioral Health Utilization Mgmt Clinician, Senior

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 Work In this role, you will: Perform prospective & concurrent utilization reviews and first level determination approvals for members admitted to facilities using BSC evidenced based guidelines, policies and nationally recognized clinal criteria across lines of business or for a specific line of business such as Medicare as needed Gather clinical information and apply the appropriate clinical criteria/guideline, policy, procedure and clinical judgment to render coverage determination/recommendation along the continuum of care facilitates including effective discharge planning at levels of care appropriate for the members needs and acuity; prepare and present cases to Medical Director (MD) for medical director oversight and necessity determination Provide information to facilities and providers regarding community treatment resources, mental health care management programs, company policies and procedures, and medical necessity criteria Work with multidisciplinary teams to support members using an integrated team-based approach including Interdisciplinary Team Meetings and case consultations with Medical Director and/or Licensed Manager Recognize the members’ right to self-determination as it relates to the ethical principle of autonomy, including the members/family’s right to make informed choices that may not promote the best outcomes, as determined by the healthcare team Support team through consistent and successful caseload management and workload to achieve team goals, regulatory timelines, and accreditation standards Your Knowledge and Experience Current unrestricted CA license (LCSW, LMFT, LPCC, PhD/PsyD or RN with Behavioral Health experience) required Advanced degree commensurate with field is preferred Requires at least five (5) years of prior experience in 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 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 The role allows employees to work virtually full-time, however employees will be expected to come into the office based on business needs. #LI-JB1 ABOUT THE TEAM About Blue Shield of California As of January 2025, Blue Shield of California became a subsidiary of Ascendiun. Ascendiun is a nonprofit corporate entity that is the parent to a family of organizations including Blue Shield of California and its subsidiary, Blue Shield of California Promise Health Plan; Altais, a clinical services company; and Stellarus, a company designed to scale healthcare solutions. Together, these organizations are referred to as the Ascendiun Family of Companies. At Blue Shield of California, our mission is to create a healthcare system worthy of our family and friends and sustainably affordable. We are transforming health care in a way that genuinely serves our nonprofit mission by lowering costs, improving quality, and enhancing the member and physician experience. To achieve our mission, we foster an environment where all employees can thrive and contribute fully to address the needs of the various communities we serve. We are committed to creating and maintaining a supportive workplace that upholds our values and advances our goals. Blue Shield is a U.S. News Best Company to work for, a Deloitte U.S. Best Managed Company and a Top 100 Inspiring Workplace. We were recognized by Fair360 as a Top Regional Company, and one of the 50 most community-minded companies in the United States by Points of Light. Here at Blue Shield, we strive to make a positive change across our industry and communities – join us! Our Values: Honest. We hold ourselves to the highest ethical and integrity standards. We build trust by doing what we say we're going to do and by acknowledging and correcting where we fall short. Human. We strive to listen and communicate effectively, showing empathy by understanding others' perspectives. Courageous. We stand up for what we believe in and are committed to the hard work necessary to achieve our ambitious goals. Our Workplace Model We believe in fostering a workplace environment that balances purposeful in-person collaboration with flexibility - providing clear expectations while respecting the diverse needs of our workforce. Our workplace model is designed around intentional in-person interaction, collaboration, connection, creativity and flexibility: For most teams, this means coming into the office two days per week. Employees living more than 50 miles from an office location, out of state employees, and employees in certain member-facing roles should work with their manager to determine in-office time based on business need. For employees with medical conditions that may impact their ability to work in-office, we are committed to engaging in an interactive process and providing reasonable accommodations to ensure their work environment is conducive to their success and well-being. The Company reserves the right to require more presence in the office based on business needs, and requirements are subject to change with periodic reviews. Physical Requirements: Office Environment - roles involving part to full time schedule in Office Environment. Based in our physical offices and work from home office/deskwork - Activity level: Sedentary, frequency most of work day. Equal Employment Opportunity: External hires must pass a background check/drug screen. Qualified applicants with arrest records and/or conviction records will be considered for employment in a manner consistent with Federal, State and local laws, including but not limited to the San Francisco Fair Chance Ordinance. All qualified applicants will receive consideration for employment without regards to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran status or disability status and any other classification protected by Federal, State and local laws.