Behavioral Health Utilization Reviewer

Job not on LinkedIn

🔥 7 hours ago

⚜️ Louisiana – Remote

⚜️ Louisiana – Remote

⏰ Full Time

🟡 Mid-level

🟠 Senior

🦅 H1B Visa Sponsor

This company has sponsored H1B visas in the past.

👻 Ghost score 12%

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Blue Cross and Blue Shield of Louisiana

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

Founded 1934

🏥 Healthcare

🛡️ Insurance

⚕️ Healthcare Insurance

Healthcare • Insurance • Healthcare Insurance

Blue Cross and Blue Shield of Louisiana is an independent licensee of the Blue Cross Blue Shield Association, offering a range of health insurance products and services in the state of Louisiana. The company provides health, dental, and travel insurance options, including Medicare Advantage plans such as HMO and PPO. They focus on delivering comprehensive healthcare coverage through various plans to meet varying customer needs, while partnering with doctors, hospitals, and clinics to ensure quality care and support. Additionally, the company emphasizes wellness programs, cost-saving opportunities, and accessibility for its members.

📋 Description

• Conduct clinical reviews of behavioral health service requests, claims, and appeals • Review pre-authorization requests, concurrent reviews, and retrospective behavioral health claims • Apply InterQual and medical policy criteria to document medical necessity • Refer cases not meeting criteria to the Psychiatric Medical Director for secondary review • Support the appeals department in reviewing provider and member appeals within regulatory timelines • Interact with behavioral health care providers regarding level-of-care and service decisions • Document clinical decisions and rationale in the utilization management system • Communicate determinations to providers and members by phone and written correspondence • Analyze behavioral health member data to improve quality and appropriate service utilization • Collaborate with Case Management, Quality, Provider Relations, and other internal departments • Maintain compliance with CMS, NCQA, URAC, and other state, federal, and accreditation requirements • Participate in audits, training, and quality-improvement initiatives • Perform other job-related duties within the scope of responsibilities

🎯 Requirements

• Residency in or relocation to Louisiana is preferred • Must be authorized to work for Louisiana Blue in the United States without employer-sponsored immigration support • Bachelor’s degree in nursing, healthcare, or a related field OR master’s degree in social work, counseling, or behavioral health • A Louisiana RN license can replace the bachelor’s degree • A Louisiana LPN license plus 2 years of related experience can replace the bachelor’s degree • At least 3 years of clinical or patient care experience in behavioral health • Must hold one of: LPC, PLPC, LCSW, LMFT, LMSW, LPN, or RN license • Strong clinical assessment and critical-thinking skills • Excellent communication and teamwork skills • Good understanding of behavioral health conditions and treatments • Ability to work independently and follow policies • Preferred: experience in managed care or health insurance • Preferred: familiarity with CPT codes and billing practices • Preferred: experience with Medicare and Commercial populations • Preferred: proficiency in electronic health records and case management systems • Ability to meet the physical demands and essential functions of the role • Must complete background and pre-employment drug screening after an offer and before hire • Individuals convicted of a felony involving dishonesty or breach of trust must obtain written consent from their state insurance commissioner to work in the insurance industry

🏖️ Benefits

• Resources to live well and be healthy • Continued learning and skill development • Professional growth opportunities • Opportunities to serve local communities • Reasonable accommodations for individuals with disabilities • Smoke- and tobacco-free workplace • Background and pre-employment drug screening