Your Role

The Behavioral Health Utilization Management team performs prospective utilization review for our members and correctly applies the guidelines for nationally recognized levels of care. They collaborate directly with the Member, Member's Family, and Interdisciplinary Care Team to achieve consensus and promote positive Member health outcomes through the assessment, planning, implementation, and evaluation of the Member's Care Plan. The Licensed Clinician, Senior will report to the Manager, Behavioral Health Utilization Management. In this role you will be working with both the Utilization and Care Management teams, who provide utilization management, telephonic triage and care management assistance to members requesting access to Applied Behavioral Analysis (ABA) benefit. This role has a primary function of utilization management and case management for our members seeking Behavioral Health Treatment (BHT).

Your Work

In this role, you will:

• Review Board Certified Behavior Analyst (BCBA) Assessments submitted by providers for adherence to BACB "best practice" guidelines
• Review requests for Functional Behavioral Assessments (FBA) submitted by providers for medical necessity of request
• Review for medical necessity, coding accuracy, medical policy compliance and contract compliance
• Perform prospective utilization reviews and first level determination approvals for members using BSC evidenced based guidelines, policies and/or nationally recognized clinal criteria
• 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 intervenes or as clinically appropriate
• Provide peer-to-peer case consultation to BCBA and other network providers to support treatment planning and maximize member progress. Collaborate with providers to support members treatment plan and care needs
• Act as a liaison with parents and the health care community to ensure continuum of care and support for members
• Support team through consistent and successful caseload management and workload to achieve team goals, regulatory timelines, and accreditation standards
• Provide information to members and providers regarding community treatment resources, mental health managed care 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 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

Your Knowledge and Experience

• Master's degree in psychology or a related field
• Possesses an active BCBA certification
• At least 5 years of experience as a BCBA
• Expert knowledge of Applied Behavior Analysis and Autism Spectrum Disorders
• Considerable knowledge of Managed Care and the different lines of business
• Demonstrated ability to deliver training to varied audiences and conduct effective meetings
• Experience in a managed health care environment with regards to BHT services
• Ability to identify problems and works towards problem resolution independently, seeking guidance as needed
• Ability to represent the health plan in a professional and knowledgeable fashion
• Ability to express ideas clearly in both written and oral communications
• Ability to develop, organize, analyze, and implement processes and procedures
• Proficiency with Microsoft applications including Word, Excel, Outlook, and Teams
• Effective interpersonal skills

Pay Range:

The pay range for this role is: $ 87230.00 to $ 130900.00 for California.

Note:

Please note that this range represents the pay range for this and many other positions at Blue Shield that fall into this pay grade. Blue Shield salaries are based on a variety of factors, including the candidate's experience, location (California, Bay area, or outside California), and current employee salaries for similar roles.