Job Description
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

Qualifications
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.
About the Team
Blue Shield of California's mission is to ensure all Californians have access to high-quality health care at a sustainably affordable price. We are transforming health care in a way that genuinely serves our nonprofit mission by lowering costs, improving quality, and enhancing the member and physician experience.
To fulfill our mission, we must ensure a diverse, equitable, and inclusive environment where all employees can be their authentic selves and fully contribute to meet the needs of the multifaceted communities we serve. Our continued commitment to diversity, equity, and inclusion upholds our values and advances our goal of creating a healthcare system that is worthy of our family and friends while addressing health disparities, promoting social justice, and integrating health equity through our products, business practices, and presence as a corporate citizen.
Blue Shield has received awards and recognition for being a certified Fortune 100 Best Companies to Work, Military Friendly Employer, People Companies that Care, a Leading Disability Employer, and one of California's top companies in volunteering and giving. Here at Blue Shield, we strive to make a positive change across our industry and communities - join us!
Our Values:

• Honest . We hold ourselves to the highest ethical and integrity standards. We build trust by doing what we say we're going to do and by acknowledging and correcting where we fall short.
• Human . We strive to be our authentic selves, listening and communicating effectively, and showing empathy towards others by walking in their shoes.
• Courageous . We stand up for what we believe in and are committed to the hard work necessary to achieve our ambitious goals.

Our Workplace Model:
Blue Shield of California is dedicated to making work-life balance a reality. Whether you prefer to work in an office or from home, we understand flexibility is more important than ever. That's why Blue Shield is a hybrid company, offering you the opportunity to decide where you can do your best and most meaningful work.
Two ways of working: Hybrid (our default) and office

• Hybrid - In a business unit approved office a few times per year to 3 days per week, on average

• Office - In a business unit approved office 4 days a week, on average. If the role you're applying for is deemed an "Essential Role," the company has determined that the role can only be performed in a Blue Shield office or in the field and would require your to meet the office worker classification.

Physical Requirements:
Office Environment - roles involving part to full time schedule in Office Environment. Due to the current public health emergency in California, Blue Shield employees are almost all working remotely. Based in our physical offices and work from home office/deskwork - Activity level: Sedentary, frequency most of work day.
Please click here for further physical requirement detail.
Equal Employment Opportunity:
External hires must pass a background check/drug screen. Qualified applicants with arrest records and/or conviction records will be considered for employment in a manner consistent with Federal, State and local laws, including but not limited to the San Francisco Fair Chance Ordinance. All qualified applicants will receive consideration for employment without regards to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran status or disability status and any other classification protected by Federal, State and local laws.