Behavioral Health Utilization Management Clinician, Senior

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.

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 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 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 works towards problem resolution independently, seeking guidance as needed