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Clinical Review Specialist
2 months ago
The Behavioral Health Utilization Management team at Blue Shield of California performs critical reviews to ensure members receive necessary care. As a Licensed Clinician, Senior, you will report to the Manager of Behavioral Health Utilization Management and conduct clinical reviews of mental health and substance use authorization requests.
Key Responsibilities- Conduct prospective, concurrent, and retrospective utilization reviews and first-level determination approvals for members using evidence-based guidelines and nationally recognized clinical criteria.
- Ensure discharge planning at appropriate levels of care and prepare cases for Medical Director review.
- Develop and review member-centered documentation and correspondence, identifying potential quality of care issues and service delays.
- Provide information to facilities and providers on community treatment resources, mental health care management programs, and company policies.
- Interact with Physician Advisors to discuss clinical questions and concerns.
- Participate in Interdisciplinary Team Meetings and case consultations.
- Support team goals, regulatory timelines, and accreditation standards through consistent caseload management.
As a member of our team, you will have the opportunity to make a meaningful impact on the lives of our members while working in a dynamic and supportive environment.
