About the position
At Capital Blue Cross, we promise to go the extra mile for our team and our community. This promise is at the heart of our culture, and it's why our employees consistently vote us one of the “Best Places to Work in PA.” The Utilization Management Clinician position is a licensed clinical role within the Utilization Management department, responsible for processing acute and post-acute inpatient and select outpatient higher level of care requests through clinical review and the application of approved medical necessity criteria. This role requires collaboration within and across departments, operating professionally and efficiently within the framework of established policies and procedures. The clinician will process requests for acute and post-acute inpatient medical or behavioral health services, as well as intensive outpatient care, by reviewing submitted requests and applicable clinical records. They will apply approved medical necessity criteria to determine the appropriateness of the requested services. The role involves interpreting and applying various guidelines, including InterQual criteria, CMS-issued guidelines, and Capital Blue Cross Medical Policies, to ensure compliance with regulatory requirements and internal policies regarding member confidentiality. Collaboration is key in this position, as the clinician will work closely with UM department staff, including Clinical Support Specialists and Medical Directors, to make final determinations. They will also engage with Care Management staff on discharge planning and transition of care activities. Participation in weekly clinical rounds to discuss complex cases is expected, along with identifying and referring members with complex needs to appropriate programs. The clinician will also identify potential quality issues and suggest improvements in departmental processes, contributing to a culture of learning and education. The position requires strong communication, technical, analytical, and organizational skills, along with the ability to think critically and prioritize multiple tasks. A working knowledge of medical coding guidelines and familiarity with managed care principles is essential. The clinician must hold an active master's level Behavioral Health clinical license in Pennsylvania or Registered Nurse licensure, with additional certifications required within two years of employment.
Responsibilities
- Processes acute and post-acute inpatient medical or behavioral health and select intensive outpatient higher level of care requests through review of the submitted request and applicable clinical records.
- Interprets and applies InterQual criteria, CMS-issued guidelines, Capital Blue Cross Medical Policies, the CHIP handbook, FEP Medical Policies, the FEP Benefit Brochure, and/or American Society of Addiction Medicine (ASAM) guidelines to these requests as applicable to the member's product.
- Performs high acuity of care UM case reviews within the framework of applicable regulatory requirements and established policies and procedures of Capital's UM department.
- Complies with both internal policies and all regulatory requirements regarding member's confidentiality.
- Collaborates with UM department staff, including Clinical Support Specialists and Medical Directors to make a final determination, and with Care Management staff on discharge planning and transition of care activities.
- Participates in weekly clinical rounds to discuss complex members as needed and requested.
- Identifies and refers members with complex needs to the appropriate population health and/or care management program.
- Identifies and refers members with Potential Quality Issues (PQIs) through established processes to the applicable department for further review and investigation.
- Offers suggestions for improvement in departmental processes and identifies opportunities for learning and education.
- Attends and participates in company and departmental meetings and training sessions as required and requested.
- Practices within the scope of clinical license and/or certification.
Requirements
- A minimum of 5 years' experience working in a higher level of care clinical role including acute care hospital, post-acute care facility, residential treatment center, etc.
- 1 year UM experience in managed care required.
- Must have active current and unrestricted master's level Behavioral Health clinical license in the state of Pennsylvania (LMSW, LCSW, LISW, LPC, or comparable) or Registered Nurse licensure in Pennsylvania.
- Certified Case Manager (CCM) or Accredited Case Manager (ACM) certification within 2 years of employment.
Nice-to-haves
- Demonstrated ability to critically think through processes to make clinically appropriate decisions and problem solve.
- Demonstrated ability to prioritize multiple clinical and administrative tasks and assignments.
- Demonstrated ability to work independently and as part of a team.
- Demonstrated ability to interact with other departments actively and proactively, as needed, to advise, educate, and/or direct members to other clinical programs and services.
- Demonstrates openness, flexibility, problem solving, patience, and tact when interacting with members, family, providers, and peers.
- Demonstrated ability to communicate in a concise and clear manner in both written and oral communications.
Benefits
- Flexible work environment prioritizing health and wellbeing.
- Investment in training and continuing education for professional growth.
- Encouragement to volunteer in the community.
