Behavioral Health Clinical Review Manager

Are you passionate about making a meaningful impact on the lives of individuals facing mental health challenges, while working behind the scenes? If so, Utilization Management might be the perfect fit for you! In this role, you’ll play a critical part in shaping care decisions and improving outcomes, all without direct, face-to-face interaction.

What You’ll Do

• Apply your knowledge of Behavioral Health and Withdrawal Management diagnoses.
• Navigate the continuum of care and levels of care for Behavioral Health and Withdrawal Management.
• Present cases confidently and effectively during clinical rounds.
• Work independently with minimal supervision.
• Excel in a fast-paced, dynamic environment.

Our Ideal Candidates will have an RN or Social Work license and:

• 3 years - Clinical behavioral health / substance use disorder experience required
• 1 year - Must be knowledgeable about community care resources and levels of behavioral health care available.

Along with:

• 3+ years of experience in Psychiatric and/or Substance Use treatment.
• Background in Behavioral Health settings (both inpatient and outpatient).
• Prior experience in Utilization Management or Managed Care.
• Strong communication and presentation skills.
• Ability to work autonomously and manage time effectively.
• Adaptability and resilience in a rapidly changing work environment.

Why Choose Us?
This is more than a job; it’s an opportunity to make a lasting difference in people’s lives while leveraging your expertise in a collaborative, supportive setting.

Job Responsibilities

• Assists non-clinical staff in performance of administrative reviews
• Initiate referrals to ensure appropriate coordination of care.
• Seek the advice of the Medical Director when appropriate, according to policy.
• Performing comprehensive provider and member appeals, denial interpretation for letters, retrospective claim review, special review requests, and UM pre-certifications and appeals, utilizing medical appropriateness criteria, clinical judgement, and contractual eligibility.
• Various immunizations and/or associated medical tests may be required for this position.

Job Qualifications

License

• Current, active unrestricted Tennessee license in Nursing (RN) or behavioral health field (Master's level or above) (Ph.D., LCSW/LMSW, LLP, MHC, LPC, etc.) required. RN may hold a license in the state of their residence if the state is participating in the Nurse Licensure Compact Law.

Experience

• 3 years - Clinical behavioral health / substance use disorder experience required

Skills\Certifications

• Must be knowledgeable about community care resources and levels of behavioral health care available.
• Proficient in Microsoft Office (Outlook, Word, Excel and PowerPoint)
• Independent, Sound decision-making and problem-solving skills
• Excellent oral and written communication skills
• Strong interpersonal and organizational skills
• Strong analytical skills
• Positive relationship building skills and ability to engage with diverse populations
• Ability to quickly identify and prioritize member needs and provide structured and focused support and interventions

Grade: BBEX 10

Number of Openings Available

1

Worker Type:

Employee

Company:

BCBST BlueCross BlueShield of Tennessee, Inc.

Applying for this job indicates your acknowledgement and understanding of the following statements:

BCBST will recruit, hire, train and promote individuals in all job classifications without regard to race, religion, color, age, sex, national origin,citizenship, pregnancy, veteran status, sexual orientation, physical or mental disability, gender identity, or any other characteristic protected by applicable law.

Further information regarding BCBST's EEO Policies/Notices may be found by reviewing the following page:

BCBST's EEO Policies/Notices

BlueCross BlueShield of Tennessee is not accepting unsolicited assistance from search firms for this employment opportunity. All resumes submitted by search firms to any employee at BlueCross BlueShield of Tennessee via-email, the Internet or any other method without a valid, written Direct Placement Agreement in place for this position from BlueCross BlueShield of Tennessee HR/Talent Acquisition will not be considered. No fee will be paid in the event the applicant is hired by BlueCross BlueShield of Tennessee as a result of the referral or through other means.

Originally posted on Himalayas