Senior Licensed Clinician
1 month ago
The Behavioral Health Utilization Management team at Blue Shield of California performs prospective, concurrent, and retrospective utilization reviews and first-level determination approvals for members using evidence-based guidelines, policies, and nationally recognized clinical criteria across multiple lines of business.
As a Licensed Clinician, Senior, you will report to the Manager of Behavioral Health Utilization Management (BH UM) and conduct clinical reviews 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 WorkIn this role, you will:
- Perform prospective, concurrent, and retrospective utilization reviews and first-level determination approvals for members using evidence-based guidelines, policies, and nationally recognized clinical criteria across lines of business or for a specific line of business, such as Medicare as needed.
- Ensure discharge planning at levels of care appropriate for members' needs and acuity; prepare and present cases to the Medical Director (MD) for medical director oversight and necessity determination.
- Develop and review member-centered documentation and correspondence reflecting determinations in compliance with regulatory and accreditation standards and identify potential quality of care issues, service or treatment delays, and intervene or as clinically appropriate.
- Provide information to facilities and providers regarding community treatment resources, mental health care management programs, company policies and procedures, and medical necessity criteria.
- Interact with Physician Advisors to discuss clinical questions and concerns regarding specific cases.
- Actively participate in Interdisciplinary Team Meetings and case consultations with Licensed Managers.
- Recognize members' rights to self-determination as it relates to the ethical principle of autonomy, including members'/families' rights 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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