[Hiring] Behavioral Health Utilization Reviewer @Blue Cross and Blue Shield of Louisiana

Role Description

The Behavioral Health Utilization Reviewer is responsible for conducting clinical reviews of behavioral health service requests, claims, and appeals to confirm medical necessity and appropriateness of care. The reviewer applies evidence-based criteria including InterQual and/or medical policy and collaborates with the Behavioral Health Medical Director for complex cases and requests that do not meet criteria for approval. This role does not make adverse determinations based on medical necessity. This role also involves gathering information from and communicating decisions to providers and members in a clear, timely, and professional manner.

• Review pre-authorization requests, concurrent reviews, and retrospective claims for behavioral health services.
• Apply clinical guidelines (e.g., InterQual, medical policy) to document medical necessity.
• Refer cases that do not meet criteria to the Psychiatric Medical Director for secondary review.
• Review and support the appeals department in reviewing provider and member appeals in accordance with regulatory timelines.
• Interact with BH care providers as necessary to discuss level of care and/or service decisions.
• Document clinical decisions and rationale in the utilization management system.
• Communicate determinations to providers and members via phone and written correspondence.
• Analyze BH member data to improve quality and appropriate utilization of services.
• Collaborate with internal departments including Case Management, Quality, and Provider Relations.
• Maintain compliance with state, federal, and accreditation requirements (e.g., CMS, NCQA, URAC).
• Participate in audits, training, and quality improvement initiatives.

Qualifications

• Bachelor’s degree in nursing, healthcare, or a related field OR master’s degree in social work, counseling, or behavioral health.
• RN license in Louisiana can replace the Bachelor's Degree -OR- LPN license in Louisiana + 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 have one of the following licenses: LPC, PLPC, LCSW, LMFT, LMSW, LPN, or RN.
• Strong clinical assessment and critical thinking.
• Excellent communication and teamwork.
• Good understanding of behavioral health conditions and treatments.
• Able to work independently and follow policies.

Preferred Qualifications

• Experience in a managed care or health insurance setting.
• Familiarity with CPT codes and billing practices.
• Experience working with Medicare and Commercial populations.
• Proficiency in electronic health records and case management systems.

Requirements

• The Physical Demands described here are representative of those that must be met by an employee to successfully perform the Accountabilities and Essential Functions of the job.
• Job duties are performed in a normal and clean office environment with normal noise levels.
• Work is predominately done while standing or sitting.
• The ability to comprehend, document, calculate, visualize, and analyze are required.

Additional Information

• Please be sure to monitor your email frequently for communications you may receive during the recruiting process.
• Due to the high volume of applications we receive, only those most qualified will be contacted.
• To monitor the status of your application, please visit the "My Applications" section in the Candidate Home section of your Workday account.
• If you are an individual with a disability and require a reasonable accommodation to complete an application, please contact [email protected] for assistance.
• We perform background and pre-employment drug screening after an offer has been extended and prior to hire for all positions.
• We are a Drug Free Workplace. A pre-employment drug screen will be required and any offer is contingent upon satisfactory drug testing results.