Supervisor, Utilization Review - Behavioral Health

We take great strides to ensure our employees have the resources to live well, be healthy, continue learning, develop skills, grow professionally and serve our local communities. We invite you to apply for a career with Blue Cross.

Residency in or relocation to Louisiana is preferred for all positions.

POSITION PURPOSE

Responsible for overall unit performance. Responsible for personnel administration including selection, coaching, motivation, discipline, continuous improvement and compliance. Responsible for coordinating, processing and managing the evaluations of medical and claim information to ensure proper administration of contractual terms. This includes determinations about billing practices, medical necessity, medical appropriateness, levels of care, and relationships between medical conditions and services while maintaining compliance with regulatory guidelines.

NATURE AND SCOPE

Manages People

This role directly manages 5-10

This role reports to this job: Manager, Behavioral Health Operations

Necessary Contacts: In order to effectively fulfill this position, the incumbent must be in contact with: Healthcare providers, subscribers, claims, appeals, legal, networking, case management, customer service, and compliance.  

QUALIFICATIONS

Education

• Bachelor's in nursing, business administration, healthcare or a related field, masters in social work, counseling, or other behavioral health related field is required.
• Current, unrestricted RN, license in the state of Louisiana and/or in the required jurisdictions, or where services are provided can be used in lieu of a Bachelor's degree
• Current, unrestricted LPN license in the state of Louisiana and/or in the required jurisdictions, or where services are provided as well as two years of related experience can be used in lieu of a Bachelor's degree
• Four years of related healthcare payer and/or business administration experience can be used in lieu of a Bachelor's degree

Work Experience

• 3 years of direct patient care/clinical experience to include three years managed care experience or three years BCBSLA
• Care Management experience with progressive levels of responsibility and expertise required
• 1 year of leadership experience is required.

Skills and Abilities

• Ability to review claims history in a medical claims system and generate a basic report is required.
• Must demonstrate the ability to critically evaluate clinical, claim and benefit information and make independent decisions and anticipating impacts and needs.
• Comprehension and application of provider and benefit contract terms is required.
• Excellent oral/written communication skills as well as human relation skills are required.
• Excellent organizational and analytical skills are required.
• Must maintain proficiency in nursing or professional practice and state licensure through pertinent continuing education.
• Ability to make decisions, prioritize, find solutions, and work independently are required.
• Excellent interpersonal communication and administrative skills are required.
• Requires working knowledge of MS Office and related software.

Licenses and Certifications

• Current, unrestricted LPN license in the state of Louisiana and/or in the required jurisdictions, or where services are provided.
• Current, unrestricted RN license and/or compact state licensure in the state of Louisiana and/or in the required jurisdictions, or where services are provided.
• Current unrestricted LCSW or LPC license in the state of Louisiana and/or in the required jurisdictions, or where services are provided.

ACCOUNTABILITIES AND ESSENTIAL FUNCTIONS

• Administers all HR functions, including but not limited to, hiring, terminating, conducting performance reviews, setting performance standards, approving work schedules, assigning and directing workload, training and developing staff, coaching, etc. to ensure team goals are met.
• Reviews medical claims or requests for services and applies medical judgment and /or criteria in determining the benefits for pre-services and post-services according to contractual benefits, provider contracts, and limitations, (i.e. pre-existing, workman’s compensation, riders, contractual exclusions, billing practices, cosmetic or investigational procedures and medical necessity).
• Completes correspondence correctly to providers and subscribers to ensure that customers are aware of the determinations and appeal processes/rights meeting all regulatory standards.
• Prepares documentation of medi