Your Role

The Behavioral Health (BH) Utilization Management (UM) team performs prospective, concurrent, retrospective utilization reviews and first level determinations for members using BSC evidenced based guidelines, policies, and nationally recognized clinical criteria across multiple lines of business. The Behavioral Health Utilization Management, Consultant (Lead), will report to the Manager of Behavioral Health Utilization Management (BH UM). In this role you will support the clinicians with daily operations, provide coaching, and serve as the subject matter expert for the BH UM team as they conduct clinical reviews of mental health and substance use authorization requests at various levels of care for medical necessity.

Your Work

In this role, you will:

• Facilitate communication between leadership, Medical Directors, and non-clinical leads to address line staff questions and issues; escalate matters to management with recommendations or consultation as needed
• Lead onboarding/training of incoming staff, provide proactive and guided support through the onboarding process
• Maintain and gain knowledge of behavioral health utilization management through team and departmental expansion as needed
• Act as subject matter expert to review and evaluate the effectiveness of operational workflows to identify problems and develop improvements, modifications, and enhancements
• Develop and evaluate tools and materials that enhance operating efficiency, accuracy, and technical skill levels of unit staff
• Assist with audit readiness in collaboration with internal BSC partners
• Perform advanced or complicated prior authorization and concurrent utilization reviews and first level determinations for members using non-profit association guidelines ensure discharge (DC) planning at levels of care appropriate for the members needs and acuity; prepare and present cases to Medical Director (MD) for oversight and necessity determination
• Identify process and control improvement opportunities and provide recommendations that help improve the effectiveness, efficiency and/or economic value of a control or process
• Provide guidance, coaching and training on internal behavioral health utilization management processes to other employees across the company as appropriate
• Lead, manage, and execute other special projects and team initiatives as assigned
• Lead team huddles/meetings to support processes and collaboration of team members
• 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 seven (7) years of prior experience in healthcare related field
• Experience operating in a lead role or equivalent leadership training is preferred
• Five (5) years conducting Behavioral Health Utilization Management for a health insurance plan or managed care environment preferred
• Deep knowledge of Behavioral Health Utilization Management including ability to apply and interpret admission and continued stay clinical against nonprofit association 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