Utilization Management - Licensed Clinician, Senior

Your Role

The Behavioral Health Utilization Management team performs prospective, concurrent, retrospective utilization reviews and first level determination approvals for members using BSC evidenced based guidelines, policies, and nationally recognized clinal criteria across multiple lines of business. The Licensed 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.

Your Knowledge and Experience

• Requires 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
• Bachelor of Science or advanced degree preferred
• Requires at least five (5) years of prior experience in 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 including but not limited to MCG guidelines, nonprofit association guidelines, and various Medicare guidelines
• Proficient with Microsoft Excel, Outlook, Word, Power Point, and the ability to learn and utilize multiple systems/databases
• Excellent analytical, communication skills, written skills, time management, and organizational skills
• Possess outstanding interpersonal, organizational, and communication skills, positive attitude, and high level of initiative
• Ability to identify problems and works towards problem resolution independently, seeking guidance as needed