What are the responsibilities and job description for the Behavioral Health Review Clinician position at Blue Shield of California?
Job Summary
We are seeking a highly skilled Medical Necessity Analyst - Mental Health to join our Behavioral Health Utilization Management team. As a key member of our team, you will play a critical role in ensuring that our members receive the necessary care and services to achieve optimal health outcomes.
About the Role
The ideal candidate will have a strong background in clinical case management and experience working with mental health and substance use populations. You will be responsible for conducting clinical reviews of authorization requests, gathering clinical information, and applying clinical criteria to render coverage determinations.
Responsibilities
- Conduct clinical reviews of authorization requests for mental health and substance use services.
- Gather clinical information from providers, facilities, and other stakeholders.
- Apply clinical criteria to determine medical necessity and render coverage determinations.
- Collaborate with multidisciplinary teams to support members and ensure seamless transitions across care settings.
- Communicate with providers, facilities, and other stakeholders to clarify expectations and resolve issues.
Requirements
To be successful in this role, you will need:
- A Registered Nurse or Clinically Licensed Behavioral Health Practitioner with a current unrestricted CA license (LCSW, LMFT, LPCC, Licensed Psychologist, or Registered Nurse (RN) with Behavioral Health experience).
- A Bachelor of Science or advanced degree.
- At least five (5) years of prior experience in a healthcare-related field.
- Three (3) years conducting Utilization Management for a health insurance plan or managed care environment preferred.
- Strong understanding of behavioral health utilization management, including application of multiple standardized clinical criteria sets.
- Proficient with Microsoft Excel, Outlook, Word, PowerPoint, and the ability to learn and utilize multiple systems/databases.
