Behavioral Health Clinical Review Manager

BlueCross BlueShield of Tennessee•Chattanooga, TN

4d•Remote

About The Position

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. 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. BCBST is a remote-first organization with many employees working primarily from their homes. Each position within the company is classified as either fully remote, partially remote, or office based. BCBST hires employees for remote positions from across the U.S. with the exception of the following states: California, Massachusetts, New Hampshire, New Jersey, and New York. Applicants living in these states may move to an approved state prior to starting a position with BCBST at their own expense. If the position requires the individual to reside in Chattanooga, TN, they may be eligible for relocation assistance.

Requirements

RN or Social Work license
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.
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.
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.
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

Nice To Haves

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

Responsibilities

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.
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.