What are the responsibilities and job description for the Healthcare Utilization Management Specialist position at Blue Shield of California?
Company Overview
We are Blue Shield of California, a leading health insurance company dedicated to providing high-quality healthcare services to our members. Our mission is to improve the health and well-being of our communities, and we are seeking a skilled Clinical Case Manager - Behavioral Health to join our team.
About the Role
We are looking for an experienced Clinical Case Manager - Behavioral Health to conduct clinical reviews of mental health and substance use authorization requests. You will 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.
Responsibilities
- 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.
- Perform prospective, concurrent, and retrospective utilization reviews and first-level determination approvals for members admitted to inpatient facilities using BSC evidenced-based guidelines, policies, and nationally recognized clinical criteria.
- 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 facilities.
- Provide information to facilities and providers regarding community treatment resources, mental health care management programs, company policies, and procedures.
- Work with multidisciplinary teams to support members using an integrated team-based approach.
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.
