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Licensed Clinician, Senior
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- The Behavioral Health Utilization Management team performs prospective, concurrent, retrospective utilization reviews and first level determination approvals for members using BSC evidenced based guidelines, policies, and nationally recognized clinal criteria across multiple lines of business.
- The Licensed Clinician, Senior, 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.
- Perform prospective, concurrent and retrospective utilization reviews and first level determination approvals for members 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
- Ensure discharge (DC) 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
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