What are the responsibilities and job description for the BH Clinical Review Manager position at BlueCross BlueShield of Tennessee?
Our Total Health Management team is looking for Behavioral Health Clinical Review Manager. Are you passionate about making a meaningful impact in the lives of individuals struggling with mental health issues, but prefer to work behind the scenes? Consider a career in Utilization Management! This role allows you to significantly influence someone's day-to-day life without direct, face-to-face contact.
We are looking for an individual who understands Behavioral Health and Withdrawal Management Diagnoses and would be able to navigate the continuum and levels of care process for Behavioral Health Withdrawal Management. In this role you, will need to present cases effectively during rounds. You will need to be able to work independently with minimal supervision.
The ideal candidate will have excellent communication and presentation skills, in addition to experience with:
- Behavioral Health Settings: Inpatient and Outpatient.
- Utilization Management or Managed Care.
- Working autonomously and managing time efficiently.
- Thriving in a dynamic and fast-paced environment.
Job Responsibilities
- Assists non-clinical staff in performance of administrative reviews
- Initiate referrals to ensure appropriate coordination of care.
- Seek the advice of the Medical Director when appropriate, according to policy.
- Performing comprehensive provider and member appeals, denial interpretation for letters, retrospective claim review, special review requests, and UM pre-certifications and appeals, utilizing medical appropriateness criteria, clinical judgement, and contractual eligibility.
- Various immunizations and/or associated medical tests may be required for this position.
Job Qualifications
License
- Current, active unrestricted Tennessee license in Nursing (RN) or behavioral health field (Master's level or above) (Ph.D., LCSW/LMSW, LLP, MHC, LPC, etc.) required. RN may hold a license in the state of their residence if the state is participating in the Nurse Licensure Compact Law.
Experience
- 3 years - Clinical behavioral health / substance use disorder experience required
Skills\Certifications
- Must be knowledgeable about community care resources and levels of behavioral health care available.
- Proficient in Microsoft Office (Outlook, Word, Excel and PowerPoint)
- Independent, Sound decision-making and problem-solving skills
- Excellent oral and written communication skills
- Strong interpersonal and organizational skills
- Strong analytical skills
- Positive relationship building skills and ability to engage with diverse populations
- Ability to quickly identify and prioritize member needs and provide structured and focused support and interventions
Number of Openings Available:
1
Worker Type:
Employee
Company:
BCBST BlueCross BlueShield of Tennessee, Inc.
Applying for this job indicates your acknowledgement and understanding of the following statements:
BCBST will recruit, hire, train and promote individuals in all job classifications without regard to race, religion, color, age, sex, national origin, citizenship, pregnancy, veteran status, sexual orientation, physical or mental disability, gender identity, or any other characteristic protected by applicable law.
Further information regarding BCBST's EEO Policies/Notices may be found by reviewing the following page:
BCBST's EEO Policies/Notices
BlueCross BlueShield of Tennessee is not accepting unsolicited assistance from search firms for this employment opportunity. All resumes submitted by search firms to any employee at BlueCross BlueShield of Tennessee via-email, the Internet or any other method without a valid, written Direct Placement Agreement in place for this position from BlueCross BlueShield of Tennessee HR/Talent Acquisition will not be considered. No fee will be paid in the event the applicant is hired by BlueCross BlueShield of Tennessee as a result of the referral or through other means.
Tobacco-Free Hiring Statement
To further our mission of peace of mind through better health, effective 2017, BlueCross BlueShield of Tennessee and its subsidiaries no longer hire individuals who use tobacco or nicotine products (including but not limited to cigarettes, cigars, pipe tobacco, snuff, chewing tobacco, gum, patch, lozenges and electronic or smokeless cigarettes) in any form in Tennessee and where state law permits. A tobacco or nicotine free hiring practice is part of an effort to combat serious diseases, as well as to promote health and wellness for our employees and our community. All offers of employment will be contingent upon passing a background check which includes an illegal drug and tobacco/nicotine test. An individual whose post offer screening result is positive for illegal drugs or tobacco/nicotine and/or whose background check is verified to be unsatisfactory, will be disqualified from employment, the job offer will be withdrawn, and they may be disqualified from applying for employment for six (6) months from the date of the post offer screening results.
Resources to help individuals discontinue the use of tobacco/nicotine products include smokefree.gov or 1-800-QUIT-NOW.
