263 Management jobs in Antioch

Your Role

The Medical Management team ensures that Blue Shield is on the cutting edge of medical, medication, and payment policy to accelerate the emergence of a value-based health care system in California. The Senior Medical Director FEP Prior Authorization and Post Review will report to the Vice President, Medical Management or their designee. In this role you will deliver and collaborate on clinical review activities, which includes management of the physician processes in support of utilization management and transactional functions for Federal Employee Program (FEP) membership. These functions include performance of pre-service and retrospective utilization review, Appeals and Grievances, and provider claims dispute reviews.

The Senior Medical Director for FEP Prior Authorization and Post Review facilitates performance management and goals in alignment with organizational goals for the FEP membership. Moreover, this role leads or meaningfully contributes to the Blue Shield priorities and transformative initiatives that continue to improve the health and wellbeing of Blue Shield of California FEP members. You will also provide direction and leadership in compliance to regulatory requirements and key operational metrics and work collaboratively with the VP of Medical Management and Medical Directors in Utilization Management to achieve these goals.

Your Work

In this role, you will:

• Complete assigned clinical reviews (IP Admission and Concurrent, Lower Level of Care, Preservice requests, Post-service medical claim review, Provider Claims Disputes, Medical pharmacy, or others) within compliance standards while supporting clinical staff in maintaining high quality clinical reviews and work products and process improvement and optimization efforts for FEP membership
• Provides clinical leadership and HR oversight for FEP Medical Director team
• Partner closely with the VP Medical Management and Medical Directors in Utilization Management to develop improved utilization of effective and appropriate services, and support operational implementation of transformation initiatives for the FEP membership
• Support VP, Medical Management and Medical Directors in Utilization Management in coordinating the care of FEP membership to provide access to high-quality health care to these members
• Serve as a clinical, regulatory and quality improvement resource and clinical thought leader within the organization
• Support Vice President, Medical Management in strategic initiatives whether by proposing clinical initiatives, providing expert input, shaping the strategy, and/or serving as the initiative driver
• Collaborate with teams in the implementation and operation of assigned initiatives
• Understands and abides by all departmental policies and procedures as well as the organization’s Standards of Conduct and Corporate Compliance Program
• Attends mandatory Corporate Compliance Program education sessions, as required for this position, including the annual mandatory Standards of Conduct class
• Participates in assigned Committees
• Abides by all applicable laws and regulations as mandated by state and federal law
• Any other assigned duties

Your Knowledge and Experience

• A Medical degree (M.D./D.O.)  
• Completed residency preferably in adult based primary care specialty (e.g. internal medicine, family practice)
• Maintain active, unrestricted California State Medical License required
• Maintain Board Certification in one of ABMS categories required (preferably Internal Medicine)
• Minimum of 2 years of previous medical leadership experience
• Minimum 5 years direct patient care experience post residency in: Internal Medicine (e.g. Neurology, Rheumatology), Family Practice (e.g. Psychiatry, Geriatrics, OBGYN), Adult based care, Internal Medicine (e.g. Neurology, Rheumatology), Family Practice (with 5+ years of inpatient experience), Psychiatry, Geriatrics, OBGYN
• Demonstrated proficiency in at least 3 of the following: MEDICARE/MEDICARE STARS, NCQA/URAC/Quality Programs, Policies/Procedure, Litigation, SIU/Waste/Fraud/Abuse, Appeals/Grievances, Case Management/Population Health
• Knowledge and skilled application of national evidence-based medical necessity criteria references (MCG or InterQual)
• An ability to work independently to achieve objectives and resolve issues in ambiguous circumstances
• Clear, compelling communication skills with demonstrated ability to motivate, guide, influence, and lead others, including the ability to translate detailed analytic analysis and complex materials into compelling communications
• Strong collaboration skills to effectively work within a team that may consist of diverse individuals who bring a variety of different skills ranging from medical to project management and more
• Excellent written and verbal communication skills
• Excellent analytical, time management and organizational skills
• Proficient with computer programs such as Microsoft Excel, Outlook, Word, and PowerPoint

Your Role

The Medical Management team ensures that Blue Shield is on the cutting edge of medical, medication, and payment policy to accelerate the emergence of a value-based health care system in California. The Senior Medical Director FEP Prior Authorization and Post Review will report to the Vice President, Medical Management or their designee. In this role you will deliver and collaborate on clinical review activities, which includes management of the physician processes in support of utilization management and transactional functions for Federal Employee Program (FEP) membership. These functions include performance of pre-service and retrospective utilization review, Appeals and Grievances, and provider claims dispute reviews.

The Senior Medical Director for FEP Prior Authorization and Post Review facilitates performance management and goals in alignment with organizational goals for the FEP membership. Moreover, this role leads or meaningfully contributes to the Blue Shield priorities and transformative initiatives that continue to improve the health and wellbeing of Blue Shield of California FEP members. You will also provide direction and leadership in compliance to regulatory requirements and key operational metrics and work collaboratively with the VP of Medical Management and Medical Directors in Utilization Management to achieve these goals.

Your Work

In this role, you will:

• Complete assigned clinical reviews (IP Admission and Concurrent, Lower Level of Care, Preservice requests, Post-service medical claim review, Provider Claims Disputes, Medical pharmacy, or others) within compliance standards while supporting clinical staff in maintaining high quality clinical reviews and work products and process improvement and optimization efforts for FEP membership
• Provides clinical leadership and HR oversight for FEP Medical Director team
• Partner closely with the VP Medical Management and Medical Directors in Utilization Management to develop improved utilization of effective and appropriate services, and support operational implementation of transformation initiatives for the FEP membership
• Support VP, Medical Management and Medical Directors in Utilization Management in coordinating the care of FEP membership to provide access to high-quality health care to these members
• Serve as a clinical, regulatory and quality improvement resource and clinical thought leader within the organization
• Support Vice President, Medical Management in strategic initiatives whether by proposing clinical initiatives, providing expert input, shaping the strategy, and/or serving as the initiative driver
• Collaborate with teams in the implementation and operation of assigned initiatives
• Understands and abides by all departmental policies and procedures as well as the organization’s Standards of Conduct and Corporate Compliance Program
• Attends mandatory Corporate Compliance Program education sessions, as required for this position, including the annual mandatory Standards of Conduct class
• Participates in assigned Committees
• Abides by all applicable laws and regulations as mandated by state and federal law
• Any other assigned duties

Your Knowledge and Experience

• A Medical degree (M.D./D.O.)  
• Completed residency preferably in adult based primary care specialty (e.g. internal medicine, family practice)
• Maintain active, unrestricted California State Medical License required
• Maintain Board Certification in one of ABMS categories required (preferably Internal Medicine)
• Minimum of 2 years of previous medical leadership experience
• Minimum 5 years direct patient care experience post residency in: Internal Medicine (e.g. Neurology, Rheumatology), Family Practice (e.g. Psychiatry, Geriatrics, OBGYN), Adult based care, Internal Medicine (e.g. Neurology, Rheumatology), Family Practice (with 5+ years of inpatient experience), Psychiatry, Geriatrics, OBGYN
• Demonstrated proficiency in at least 3 of the following: MEDICARE/MEDICARE STARS, NCQA/URAC/Quality Programs, Policies/Procedure, Litigation, SIU/Waste/Fraud/Abuse, Appeals/Grievances, Case Management/Population Health
• Knowledge and skilled application of national evidence-based medical necessity criteria references (MCG or InterQual)
• An ability to work independently to achieve objectives and resolve issues in ambiguous circumstances
• Clear, compelling communication skills with demonstrated ability to motivate, guide, influence, and lead others, including the ability to translate detailed analytic analysis and complex materials into compelling communications
• Strong collaboration skills to effectively work within a team that may consist of diverse individuals who bring a variety of different skills ranging from medical to project management and more
• Excellent written and verbal communication skills
• Excellent analytical, time management and organizational skills
• Proficient with computer programs such as Microsoft Excel, Outlook, Word, and PowerPoint

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, Experienced, 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 utilization reviews and first level determination approvals for members admitted to facilities using BSC evidenced based guidelines, policies and nationally recognized clinal 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 Medical Director (MD) for medical director 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 Medical Director and/or Licensed Manager
• Recognize the members right to self-determination as it relates to the ethical principle of autonomy, including the members/family's right to make informed choices that may not promote the best outcomes, as determined by the healthcare team 
• Support team through consistent and successful caseload management and workload to achieve team goals, regulatory timelines, and accreditation standards

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 three (3) years of prior experience in healthcare related field
• One (1) year conducting Behavioral Health Utilization Management for a health insurance plan or managed care environment preferred
• Strong understanding of Behavioral Health Utilization Management including ability to apply and interpret admission and continued stay criteria of multiple standardized clinical criteria sets including but not limited to MCG guidelines, nonprofit association guidelines, and various Medicare guidelines
• 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 works towards problem resolution independently, seeking guidance as needed

Your Role

The Medical Management team ensures that Blue Shield is on the cutting edge of medical, medication, and payment policy to accelerate the emergence of a value-based health care system in California. The Senior Medical Director FEP Prior Authorization and Post Review will report to the Vice President, Medical Management or their designee. In this role you will deliver and collaborate on clinical review activities, which includes management of the physician processes in support of utilization management and transactional functions for Federal Employee Program (FEP) membership. These functions include performance of pre-service and retrospective utilization review, Appeals and Grievances, and provider claims dispute reviews.

The Senior Medical Director for FEP Prior Authorization and Post Review facilitates performance management and goals in alignment with organizational goals for the FEP membership. Moreover, this role leads or meaningfully contributes to the Blue Shield priorities and transformative initiatives that continue to improve the health and wellbeing of Blue Shield of California FEP members. You will also provide direction and leadership in compliance to regulatory requirements and key operational metrics and work collaboratively with the VP of Medical Management and Medical Directors in Utilization Management to achieve these goals.

Your Work

In this role, you will:

• Complete assigned clinical reviews (IP Admission and Concurrent, Lower Level of Care, Preservice requests, Post-service medical claim review, Provider Claims Disputes, Medical pharmacy, or others) within compliance standards while supporting clinical staff in maintaining high quality clinical reviews and work products and process improvement and optimization efforts for FEP membership
• Provides clinical leadership and HR oversight for FEP Medical Director team
• Partner closely with the VP Medical Management and Medical Directors in Utilization Management to develop improved utilization of effective and appropriate services, and support operational implementation of transformation initiatives for the FEP membership
• Support VP, Medical Management and Medical Directors in Utilization Management in coordinating the care of FEP membership to provide access to high-quality health care to these members
• Serve as a clinical, regulatory and quality improvement resource and clinical thought leader within the organization
• Support Vice President, Medical Management in strategic initiatives whether by proposing clinical initiatives, providing expert input, shaping the strategy, and/or serving as the initiative driver
• Collaborate with teams in the implementation and operation of assigned initiatives
• Understands and abides by all departmental policies and procedures as well as the organization’s Standards of Conduct and Corporate Compliance Program
• Attends mandatory Corporate Compliance Program education sessions, as required for this position, including the annual mandatory Standards of Conduct class
• Participates in assigned Committees
• Abides by all applicable laws and regulations as mandated by state and federal law
• Any other assigned duties

Your Knowledge and Experience

• A Medical degree (M.D./D.O.)  
• Completed residency preferably in adult based primary care specialty (e.g. internal medicine, family practice)
• Maintain active, unrestricted California State Medical License required
• Maintain Board Certification in one of ABMS categories required (preferably Internal Medicine)
• Minimum of 2 years of previous medical leadership experience
• Minimum 5 years direct patient care experience post residency in: Internal Medicine (e.g. Neurology, Rheumatology), Family Practice (e.g. Psychiatry, Geriatrics, OBGYN), Adult based care, Internal Medicine (e.g. Neurology, Rheumatology), Family Practice (with 5+ years of inpatient experience), Psychiatry, Geriatrics, OBGYN
• Demonstrated proficiency in at least 3 of the following: MEDICARE/MEDICARE STARS, NCQA/URAC/Quality Programs, Policies/Procedure, Litigation, SIU/Waste/Fraud/Abuse, Appeals/Grievances, Case Management/Population Health
• Knowledge and skilled application of national evidence-based medical necessity criteria references (MCG or InterQual)
• An ability to work independently to achieve objectives and resolve issues in ambiguous circumstances
• Clear, compelling communication skills with demonstrated ability to motivate, guide, influence, and lead others, including the ability to translate detailed analytic analysis and complex materials into compelling communications
• Strong collaboration skills to effectively work within a team that may consist of diverse individuals who bring a variety of different skills ranging from medical to project management and more
• Excellent written and verbal communication skills
• Excellent analytical, time management and organizational skills
• Proficient with computer programs such as Microsoft Excel, Outlook, Word, and PowerPoint

Your Role

The Medical Management team ensures that Blue Shield is on the cutting edge of medical, medication, and payment policy to accelerate the emergence of a value-based health care system in California. The Senior Medical Director FEP Prior Authorization and Post Review will report to the Vice President, Medical Management or their designee. In this role you will deliver and collaborate on clinical review activities, which includes management of the physician processes in support of utilization management and transactional functions for Federal Employee Program (FEP) membership. These functions include performance of pre-service and retrospective utilization review, Appeals and Grievances, and provider claims dispute reviews.

The Senior Medical Director for FEP Prior Authorization and Post Review facilitates performance management and goals in alignment with organizational goals for the FEP membership. Moreover, this role leads or meaningfully contributes to the Blue Shield priorities and transformative initiatives that continue to improve the health and wellbeing of Blue Shield of California FEP members. You will also provide direction and leadership in compliance to regulatory requirements and key operational metrics and work collaboratively with the VP of Medical Management and Medical Directors in Utilization Management to achieve these goals.

Your Work

In this role, you will:

• Complete assigned clinical reviews (IP Admission and Concurrent, Lower Level of Care, Preservice requests, Post-service medical claim review, Provider Claims Disputes, Medical pharmacy, or others) within compliance standards while supporting clinical staff in maintaining high quality clinical reviews and work products and process improvement and optimization efforts for FEP membership
• Provides clinical leadership and HR oversight for FEP Medical Director team
• Partner closely with the VP Medical Management and Medical Directors in Utilization Management to develop improved utilization of effective and appropriate services, and support operational implementation of transformation initiatives for the FEP membership
• Support VP, Medical Management and Medical Directors in Utilization Management in coordinating the care of FEP membership to provide access to high-quality health care to these members
• Serve as a clinical, regulatory and quality improvement resource and clinical thought leader within the organization
• Support Vice President, Medical Management in strategic initiatives whether by proposing clinical initiatives, providing expert input, shaping the strategy, and/or serving as the initiative driver
• Collaborate with teams in the implementation and operation of assigned initiatives
• Understands and abides by all departmental policies and procedures as well as the organization’s Standards of Conduct and Corporate Compliance Program
• Attends mandatory Corporate Compliance Program education sessions, as required for this position, including the annual mandatory Standards of Conduct class
• Participates in assigned Committees
• Abides by all applicable laws and regulations as mandated by state and federal law
• Any other assigned duties

Your Knowledge and Experience

• A Medical degree (M.D./D.O.)  
• Completed residency preferably in adult based primary care specialty (e.g. internal medicine, family practice)
• Maintain active, unrestricted California State Medical License required
• Maintain Board Certification in one of ABMS categories required (preferably Internal Medicine)
• Minimum of 2 years of previous medical leadership experience
• Minimum 5 years direct patient care experience post residency in: Internal Medicine (e.g. Neurology, Rheumatology), Family Practice (e.g. Psychiatry, Geriatrics, OBGYN), Adult based care, Internal Medicine (e.g. Neurology, Rheumatology), Family Practice (with 5+ years of inpatient experience), Psychiatry, Geriatrics, OBGYN
• Demonstrated proficiency in at least 3 of the following: MEDICARE/MEDICARE STARS, NCQA/URAC/Quality Programs, Policies/Procedure, Litigation, SIU/Waste/Fraud/Abuse, Appeals/Grievances, Case Management/Population Health
• Knowledge and skilled application of national evidence-based medical necessity criteria references (MCG or InterQual)
• An ability to work independently to achieve objectives and resolve issues in ambiguous circumstances
• Clear, compelling communication skills with demonstrated ability to motivate, guide, influence, and lead others, including the ability to translate detailed analytic analysis and complex materials into compelling communications
• Strong collaboration skills to effectively work within a team that may consist of diverse individuals who bring a variety of different skills ranging from medical to project management and more
• Excellent written and verbal communication skills
• Excellent analytical, time management and organizational skills
• Proficient with computer programs such as Microsoft Excel, Outlook, Word, and PowerPoint

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, Experienced, 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 utilization reviews and first level determination approvals for members admitted to facilities using BSC evidenced based guidelines, policies and nationally recognized clinal 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 Medical Director (MD) for medical director 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 Medical Director and/or Licensed Manager
• Recognize the members right to self-determination as it relates to the ethical principle of autonomy, including the members/family's right to make informed choices that may not promote the best outcomes, as determined by the healthcare team 
• Support team through consistent and successful caseload management and workload to achieve team goals, regulatory timelines, and accreditation standards

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 three (3) years of prior experience in healthcare related field
• One (1) year conducting Behavioral Health Utilization Management for a health insurance plan or managed care environment preferred
• Strong understanding of Behavioral Health Utilization Management including ability to apply and interpret admission and continued stay criteria of multiple standardized clinical criteria sets including but not limited to MCG guidelines, nonprofit association guidelines, and various Medicare guidelines
• 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 works towards problem resolution independently, seeking guidance as needed

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, Experienced, 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 utilization reviews and first level determination approvals for members admitted to facilities using BSC evidenced based guidelines, policies and nationally recognized clinal 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 Medical Director (MD) for medical director 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 Medical Director and/or Licensed Manager
• Recognize the members right to self-determination as it relates to the ethical principle of autonomy, including the members/family's right to make informed choices that may not promote the best outcomes, as determined by the healthcare team 
• Support team through consistent and successful caseload management and workload to achieve team goals, regulatory timelines, and accreditation standards

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 three (3) years of prior experience in healthcare related field
• One (1) year conducting Behavioral Health Utilization Management for a health insurance plan or managed care environment preferred
• Strong understanding of Behavioral Health Utilization Management including ability to apply and interpret admission and continued stay criteria of multiple standardized clinical criteria sets including but not limited to MCG guidelines, nonprofit association guidelines, and various Medicare guidelines
• 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 works towards problem resolution independently, seeking guidance as needed

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, Experienced, 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 utilization reviews and first level determination approvals for members admitted to facilities using BSC evidenced based guidelines, policies and nationally recognized clinal 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 Medical Director (MD) for medical director 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 Medical Director and/or Licensed Manager
• Recognize the members right to self-determination as it relates to the ethical principle of autonomy, including the members/family's right to make informed choices that may not promote the best outcomes, as determined by the healthcare team 
• Support team through consistent and successful caseload management and workload to achieve team goals, regulatory timelines, and accreditation standards

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 three (3) years of prior experience in healthcare related field
• One (1) year conducting Behavioral Health Utilization Management for a health insurance plan or managed care environment preferred
• Strong understanding of Behavioral Health Utilization Management including ability to apply and interpret admission and continued stay criteria of multiple standardized clinical criteria sets including but not limited to MCG guidelines, nonprofit association guidelines, and various Medicare guidelines
• 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 works towards problem resolution independently, seeking guidance as needed

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, Experienced, 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 utilization reviews and first level determination approvals for members admitted to facilities using BSC evidenced based guidelines, policies and nationally recognized clinal 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 Medical Director (MD) for medical director 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 Medical Director and/or Licensed Manager
• Recognize the members right to self-determination as it relates to the ethical principle of autonomy, including the members/family's right to make informed choices that may not promote the best outcomes, as determined by the healthcare team 
• Support team through consistent and successful caseload management and workload to achieve team goals, regulatory timelines, and accreditation standards

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 three (3) years of prior experience in healthcare related field
• One (1) year conducting Behavioral Health Utilization Management for a health insurance plan or managed care environment preferred
• Strong understanding of Behavioral Health Utilization Management including ability to apply and interpret admission and continued stay criteria of multiple standardized clinical criteria sets including but not limited to MCG guidelines, nonprofit association guidelines, and various Medicare guidelines
• 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 works towards problem resolution independently, seeking guidance as needed