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 WorkIn 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 neededLead onboarding/training of incoming staff, provide proactive and guided support through the onboarding processMaintain and gain knowledge of behavioral health utilization management through team and departmental expansion as neededAct as subject matter expert to review and evaluate the effectiveness of operational workflows to identify problems and develop improvements, modifications, and enhancementsDevelop and evaluate tools and materials that enhance operating efficiency, accuracy, and technical skill levels of unit staffAssist with audit readiness in collaboration with internal BSC partnersPerform 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 determinationIdentify process and control improvement opportunities and provide recommendations that help improve the effectiveness, efficiency and/or economic value of a control or processProvide guidance, coaching and training on internal behavioral health utilization management processes to other employees across the company as appropriateLead, manage, and execute other special projects and team initiatives as assignedLead team huddles/meetings to support processes and collaboration of team membersSupport team through consistent and successful caseload management and workload to achieve team goals, regulatory timelines, and accreditation standardsYour Knowledge and ExperienceCurrent unrestricted CA license (LCSW, LMFT, LPCC, PhD/PsyD or RN with Behavioral Health experience) requiredAdvanced degree commensurate with field is preferredRequires at least seven (7) years of prior experience in healthcare related fieldExperience operating in a lead role or equivalent leadership training is preferredFive (5) years conducting Behavioral Health Utilization Management for a health insurance plan or managed care environment preferredDeep knowledge of Behavioral Health Utilization Management including ability to apply and interpret admission and continued stay clinical against nonprofit association guidelinesFamiliarity with medical terminology, diagnostic terms, and treatment modalities including ability to comprehend psychiatric evaluations, clinical notes, and lab resultsProficient with Microsoft Excel, Outlook, Word, Power Point, and the ability to learn and utilize multiple systems/databasesExcellent analytical, communication skills, written skills, time management, and organizational skillsPossess outstanding interpersonal, organizational, and communication skills, positive attitude, and high level of initiativeAbility to identify problems and works towards problem resolution independently, seeking guidance as needed

Your Role The Care Managementteam will serve to support the mission of the department, which is to provide support to patients in maintaining health and wellness in the outpatient setting. The Case Management – Nurse, Senior will report to the Manager of Care Management. In this role you will play a pivotal role in assessing member needs, providing clinical education, as well as care coordinationwith providers, medical groups, and community resources. You will be responsible for managing and coordinating patient care, ensuring that our members receive the highest quality of care and services. Care Managers perform care management (CM) activities demonstrating clinical judgement and independent analysis, collaborating with members and those involved with members’ care including clinical nurses and treating physicians.Your Work In this role, you will: Determine appropriateness of referral for CM services, mental health, and social servicesAssess members health behaviors, cultural influences and clients belief/value system. Evaluate all information related to current/proposed treatment plan and in accordance with clinical practice guidelines to identify potential barriersResearch and design treatment/care plans to promote quality of care, cost effective health care services based on medical necessity complying with contract for each appropriate plan type. Adjust plans or create contingency plans as necessaryIdentify appropriate programs and services that align with member needs and preferencesInitiate timely Individualized Care Plans (ICP) based on Health Risk Assessment (HRA) completion, participation in and documentation of Interdisciplinary meetings (ICT), assisting in transitions of care across all agesProvide Referrals to Quality Management (QM), Disease Management (DM) and Appeals and Grievance department (AGD)Conduct member care review with medical groups or individual providers for continuity of care, out of area/out of network and investigational/experimental casesResearch opportunities for improvement in assessment methodology and actively promote continuous improvement. Anticipate potential barriers while establishing realistic goals to ensure success for the member, providers, and BSCDetermine realistic goals and objectives and provide appropriate alternatives. Actively soliciting client’s involvementRecognize need for contingency plans throughout the healthcare processProvide education and support to members and their families regarding health conditions, treatment options, and community resourcesFollow up with members as appropriate to ensure they have successfully connected with recommended programs and servicesYour Knowledge and Experience Requires a current and valid CA RN License or valid RN license(s) from other state(s). Preferred licensure from a compact state. If assigned to another state, must maintain an active, unrestricted RN license in assigned state(s) or the ability to obtain required RN license (in addition to primary state license) within 90 days of hireBachelor of Science in Nursing or advanced degree preferredCertified Case Manager (CCM) Certification or is in process of completing certification when eligible based on CCM application requirementsRequires 5 years experience in nursing, healthcare, or related field A minimum of 3 years managed care experience in inpatient, outpatient, or managed care environment preferredHealth insurance/managed care experience preferredTransitions of care experience preferredStrong knowledge of healthcare delivery systems, managed care principles, and care coordinationExcellent communication skills