Medical Policy Clinician

3 weeks ago

Oakland CA, United States Blue Shield of California Full time

Your Role The Behavioral Health Utilization Management team performs prospective, concurrent, retrospective utilization reviews and first level determination approvals for members using Blue Shield of California (BSC) evidenced based guidelines, policies, and nationally recognized clinical 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.
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 across lines of business or for a specific line of business such as Medicare as needed
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 facilitates including effective discharge planning at levels of care appropriate for the members needs and acuity
Prepare and present cases to a Medical Director (MD) for oversight and necessity determination
Provide information to facilities and providers regarding community treatment resources, mental health care management programs, company policies and procedures, and medical necessity criteria
Work with multidisciplinary teams to support members using an integrated team-based approach including Interdisciplinary team meetings and case consultations with a Medical Director and/or Licensed Manager
Recognize the members right to self-determination as it relates to the ethical principle of autonomy, including the member’s/family's right to make informed choices that may not promote the best outcomes, as determined by the healthcare team 
Support the team through consistent and successful caseload management and workload to achieve team goals, regulatory timelines, and accreditation standards
Bachelor of Science or advanced degree is preferred
Three (3) years conducting Utilization Management for a health insurance plan or managed care environment is 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 is preferred 
Proficiency with Microsoft Excel, Outlook, Word, Power Point, and the ability to learn and utilize multiple systems/databases is preferred

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