23 days old

Utilization Mgmt. Review and Appeals -Behavioral Health

Blue Cross Blue Shield of Michigan
Southfield, MI 48076
  • Job Code

Responsible for providing telephonic and eReferral case review and authorization of services utilizing established mental health and substance abuse medical necessity criteria to provide quality care appropriate to clinical needs.

  • Responsible for prospective, concurrent and retrospective utilization management review of inpatient, residential, partial and outpatient (including IOP) services to ensure medical necessity, appropriate length of stay, intensity of service and level of care

  • Review and authorize requests for behavioral health and substance abuse inpatient, residential, partial and outpatient admissions utilizing medical necessity criteria

  • Evaluate and refer cases to the Medical Director for review of medical necessity, service levels, length of stay, etc. using approved clinical protocols

  • Evaluate the clinical appropriateness of requested services, coordinate care and assist with discharge planning

  • Follow out of area/out of network services and make recommendations on patient transfer to in-network services and/or alternative plans of care

  • Identify and document quality of care issues; resolve or route to appropriate area for resolution

  • Identify potential case management/disease management needs and make appropriate referrals

  • Processes referral and triage calls from members to assist them in finding the appropriate behavioral health services/providers when needed

  • Manage member crises calls transferred internally or received directly to the Behavioral Health Department. This includes assessing the member and contacting community emergency resources to coordinate transport for face to face evaluation of the members needs

  • Conduct outreach calls to members and providers related to various HEDIS measures

  • Process appeal requests initiated by providers, facilities and members

  • Perform other related duties as required
Departmental Preference:

Will also include Licensed Behavior Analyst LBA as potential candidates.

" Qualifications"

  • Bachelors degree in Nursing, or an Associates degree in Nursing with a Bachelors degree in allied health or related field, or Masters degree in Social Work, Psychology or Counseling required

  • Three (3) years of clinical experience treating mental health and substance abuse disorders required

  • One (1) year health insurance plan experience or managed care experience preferred

  • Current unrestricted State of Michigan clinical license (RN, LMSW, LP, LPC, or LLP) required

  • Demonstrates clinical knowledge and experience relative to patient care and the health care delivery process

  • Must have proficient knowledge of evidence based practices for each disorder and current trends in the Behavioral Health Field

  • Must have basic computer knowledge, typing capability and proficiency in Microsoft Word and Outlook

  • Must be proficient in multi-tasking

  • Knowledge of applicable accreditation standards, local, state and federal regulations

  • Knowledge of current behavioral health medications

  • Knowledge of HIPAA regulations

  • Familiarity with InterQual criteria, crises call interventions and alternate care

  • Knowledge of current trends in related fields

  • Knowledge of benefits

  • Effective written and verbal communication and feedback

  • Effective customer service and interpersonal skills

  • Effective organizational skills, ability to prioritize and flexibility

All qualified applicants will receive consideration for employment without regard to, among other grounds, race, color, religion, sex, national origin, sexual orientation, age, gender identity, protected veteran status or status as an individual with a disability.

Posted: 2021-07-06 Expires: 2021-08-04
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Utilization Mgmt. Review and Appeals -Behavioral Health

Blue Cross Blue Shield of Michigan
Southfield, MI 48076

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