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Behavioral Health Utilization Reviewer
Blue Cross and Blue Shield of Louisiana. Conduct clinical reviews of behavioral health service requests, claims, and appeals .
Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in clinical reviews and behavioral health service requests, applying medical policy criteria to ensure compliance and quality. Proficient in communication and collaboration with healthcare providers and internal departments to enhance service utilization and patient care.
Highest-signal resume keywords
Clinical ReviewBehavioral Health AssessmentInterQual Criteria ApplicationLPC/PLPC/LCSW/LMFT/LMSW/RN LicenseElectronic Health Records Proficiency
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Clinical AssessmentCritical ThinkingBehavioral Health KnowledgeUtilization Management DocumentationCPT Code FamiliarityManaged Care ExperienceQuality Improvement InitiativesPatient Care ExperienceRegulatory ComplianceData Analysis
Soft Skills
Excellent CommunicationTeamworkIndependent WorkProblem Solving
Tools & Technologies
Utilization Management SystemCase Management SystemsElectronic Health Records
Certifications & Qualifications
LPCPLPCLCSWLMFTLMSWLPNRN
Industry Keywords
Behavioral HealthManaged CareCMS ComplianceNCQA StandardsURAC AccreditationMedicareCommercial PopulationsPre-Authorization RequestsClaims ReviewProvider Relations
About the role
Key responsibilities & impact- 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
What you’ll need- 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
Comp & perks- 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