What are the responsibilities and job description for the Medical Policy Clinician position at Blue Shield of California?
Behavioral Health Utilization Management Team
The Behavioral Health Utilization Management team performs prospective, concurrent, and retrospective utilization reviews to determine medical necessity for members using BSC evidenced-based guidelines, policies, and nationally recognized clinical criteria.
Key Responsibilities:
- Conduct clinical review of mental health and substance use authorization requests at various levels of care
- Perform prospective, concurrent, and retrospective utilization reviews and first-level determination approvals for members admitted to inpatient facilities
- Gather clinical information and apply appropriate clinical criteria/guidelines to render coverage determinations/recommendations
The Licensed Clinician, Senior, will work closely with the Manager of Behavioral Health Utilization Management (BH UM) to ensure effective discharge planning and case management.
Requirements:
- Registered Nurse or Clinically Licensed Behavioral Health Practitioner with a current unrestricted CA license
- At least five years of prior experience in a healthcare-related field
- Three years conducting Utilization Management for a health insurance plan or managed care environment preferred
This role requires a strong understanding of behavioral health utilization management, including the application of multiple standardized clinical criteria sets. The ideal candidate will possess excellent analytical, communication, and organizational skills, as well as proficiency in Microsoft Excel, Outlook, Word, PowerPoint, and the ability to learn and utilize multiple systems/databases.
