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Licensed Clinician, Consultant
2 months ago
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, Consultant, will report to the Manager of Behavioral Health Utilization Management (BH UM). In this role you will be considered the subject matter expert (SME) and will engage in project or program management activities, lead onboarding/training of incoming staff, and act as a resource to BH UM clinicians to provide support and assure quality and regulatory compliance for the department.
Your Work
In this role, you will:
- Perform prospective, concurrent and retrospective utilization reviews and first level determination approvals for members using BSC evidenced based guidelines, policies and nationally recognized clinal criteria across lines of business or for a specific line of business such as ASO, CalPERS, or Medicare as needed
- Conduct UM review activities for appropriate member treatment to meet Recommended Length of Stay based on medical necessity criteria; ensure discharge (DC) 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 determination
- Develops and reviews member centered documentation and correspondence reflecting determinations in compliance with regulatory and accreditation standards
- Act as subject matter expert to review and evaluate the effectiveness of operational workflows to identify problems and develop improvements, modifications, and enhancements
- Assist with audit readiness in collaboration with internal BSC partners
- Identify process and control improvement opportunities and provide recommendations that help improve the effectiveness, efficiency and/or economic value of a control or process
- Provide guidance, coaching and training on internal behavioral health utilization management processes to other employees across the company as appropriate
- Lead, manage, and execute other special projects and team initiatives as assigned
- Support team through consistent and successful caseload management and workload to achieve team goals, regulatory timelines, and accreditation standards
Your Knowledge and Experience
- Requires a current and unrestricted CA RN, LCSW, LMFT, LPCC or psychologist license
- Typically, requires a minimum 7 years of prior relevant experience.
- Requires deep knowledge of job area typically obtained through advanced education combined with experience
- Typically, viewed as a specialist within discipline. May have broad knowledge of project management.
- Proficient with Microsoft Excel, Outlook, Word, Power Point, and the ability to learn and utilize multiple systems/databases preferred
- Excellent analytical, communication skills, written skills, time management, and organizational skills
- Possess excellent interpersonal, organizational, and communication skills, positive attitude, and high level of initiative preferred
- Requires deep knowledge 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 preferred
- Ability to identify problems and works towards problem resolution independently, seeking guidance as needed preferred
Pay Range:
The pay range for this role is: $ 109120.00 to $ 163680.00 for California.
Note:
Please note that this range represents the pay range for this and many other positions at Blue Shield that fall into this pay grade. Blue Shield salaries are based on a variety of factors, including the candidate's experience, location (California, Bay area, or outside California), and current employee salaries for similar roles.
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