Licensed Clinician, Senior

2 weeks ago

Oakland, United States Blue Cross and Blue Shield Association 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.

Your Work

In this role, you will:

* 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

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