Senior Behavioral Health Utilization Management ...

Join to apply for the Senior Behavioral Health Utilization Management Clinician role at Blue Shield of California1 day ago Be among the first 25 applicantsJoin to apply for the Senior Behavioral Health Utilization Management Clinician role at Blue Shield of CaliforniaGet AI-powered advice on this job and more exclusive features.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.California license (LCSW, LMFT, LPCC, PhD/PsyD or RN with Behavioral Health experience) is required,In this role, you will:Perform prospective & concurrent utilization reviews and first level determination approvals for members admitted to facilities using BSC evidenced based guidelines, policies and nationally recognized clinal criteria across lines of business or for a specific line of business such as Medicare as neededGather clinical information and apply the appropriate clinical criteria/guideline, policy, procedure and clinical judgment to render coverage determination/recommendation along the continuum of care facilitates including effective discharge planning at levels of care appropriate for the members needs and acuity; prepare and present cases to Medical Director (MD) for medical director oversight and necessity determinationProvide information to facilities and providers regarding community treatment resources, mental health care management programs, company policies and procedures, and medical necessity criteriaWork 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 ManagerRecognize the members right to self-determination as it relates to the ethical principle of autonomy, including the members/family's right to make informed choices that may not promote the best outcomes, as determined by the healthcare teamSupport team through consistent and successful caseload management and workload to achieve team goals, regulatory timelines, and accreditation standardsQualificationsCurrent unrestricted CA license (LCSW, LMFT, LPCC, PhD/PsyD or RN with Behavioral Health experience) requiredAdvanced degree commensurate with field is preferredRequires at least five (5) years of prior experience in healthcare related fieldThree (3) years conducting Behavioral Health Utilization Management for a health insurance plan or managed care environment requiredSeniority levelSeniority levelMid-Senior levelEmployment typeEmployment typeFull-timeJob functionJob functionHealth Care ProviderIndustriesHospitals and Health CareReferrals increase your chances of interviewing at Blue Shield of California by 2xGet notified about new Behavioral Health Specialist jobs in Washington, United States.Washington Licensed Behavioral Health Care ManagerWe’re unlocking community knowledge in a new way. Experts add insights directly into each article, started with the help of AI. #J-18808-Ljbffr

Created: 2025-10-06