Analysis Skills, Behavioral Health, Clinical Laboratory, Communication Skills, Federal Laws and Regulations, Health Insurance, Healthcare, Identify Issues, Interpersonal Skills, Leadership, Licensed Clinical Social Worker (LCSW), Licensed Marriage and Family Therapist (LMFT), Managed Care, Medical Coding, Medical Diagnosis, Medical Terminology, Medical Treatment, Medicare, Microsoft Excel, Microsoft Outlook, Microsoft PowerPoint, Microsoft Word, Nonprofit, Organizational Skills, Problem Solving Skills, Psychiatry and Mental Health, Registered Nurse (RN), State Laws and Regulations, Time Management, Utilization Management, Work From Home, Writing Skills
Your Role
The Behavioral Health Utilization Management team performs prospective & concurrent utilization reviews and first level determinations for members using BSC evidenced based guidelines, policies, and nationally recognized clinal criteria across multiple lines of business. The Behavioral Health Utilization Management 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.
Our leadership model is about developing great leaders at all levels and creating opportunities for our people to grow - personally, professionally, and financially. We are looking for leaders that are energized by creative and critical thinking, building and sustaining high-performing teams, getting results the right way, and fostering continuous learning.
Your Knowledge and Experience
- Current unrestricted CA license (LCSW, LMFT, LPCC, PhD/PsyD or RN with Behavioral Health experience) required
- Advanced degree commensurate with field is preferred
- Requires at least five (5) years of prior experience in healthcare related field
- Three (3) years conducting Behavioral Health Utilization Management for a health insurance plan or managed care environment required
- Strong understanding of Behavioral Health Utilization Management including ability to apply and interpret admission and continued stay criteria of multiple standardized clinical criteria including but not limited to MCG guidelines, nonprofit association guidelines, and various Medicare guidelines
- ASAM 3rd Edition, ASAM 4th Edition, LOCUS and CALOCUS are preferred certifications
- Familiarity with medical terminology, diagnostic terms, and treatment modalities including ability to comprehend psychiatric evaluations, clinical notes, and lab results
- Proficient with Microsoft Excel, Outlook, Word, Power Point, and the ability to learn and utilize multiple systems/databases
- Excellent analytical, communication skills, written skills, time management, and organizational skills
- Possess outstanding interpersonal, organizational, and communication skills, positive attitude, and high level of initiative
- Ability to identify problems and work towards problem resolution independently, seeking guidance as needed
- Current unrestricted CA license (LCSW, LMFT, LPCC, PhD/PsyD or RN with Behavioral Health experience) required
- Advanced degree commensurate with field is preferred
- Requires at least five (5) years of prior experience in healthcare related field
- Three (3) years conducting Behavioral Health Utilization Management for a health insurance plan or managed care environment required
- Strong understanding of Behavioral Health Utilization Management including ability to apply and interpret admission and continued stay criteria of multiple standardized clinical criteria including but not limited to MCG guidelines, nonprofit association guidelines, and various Medicare guidelines
- ASAM 3rd Edition, ASAM 4th Edition, LOCUS and CALOCUS are preferred certifications
- Familiarity with medical terminology, diagnostic terms, and treatment modalities including ability to comprehend psychiatric evaluations, clinical notes, and lab results
- Proficient with Microsoft Excel, Outlook, Word, Power Point, and the ability to learn and utilize multiple systems/databases
- Excellent analytical, communication skills, written skills, time management, and organizational skills
- Possess outstanding interpersonal, organizational, and communication skills, positive attitude, and high level of initiative
- Ability to identify problems and work towards problem resolution independently, seeking guidance as needed
Hybrid Virtual Work
This role allows employees to work virtually full-time, however employees will be expected to come into the office based on business needs.
External hires must pass a background check/drug screen. Qualified applicants with arrest records and/or conviction records will be considered for employment in a manner consistent with Federal, State and local laws, including but not limited to the San Francisco Fair Chance Ordinance. All qualified applicants will receive consideration for employment without regards to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran status or disability status and any other classification protected by Federal, State and local laws.