Utilization Management Clinician - CCR/BH

We recognize that work is a part of life, not separate from it, and foster a flexible environment where your health and wellbeing are prioritized. At Capital you will work alongside a diverse and caring team of supportive colleagues, and be encouraged to volunteer in your community. We value your professional and personal growth by investing heavily in training and continuing education, so you have the tools to do your best as you develop your career. And by doing your best, you’ll help us live our mission of improving the health and well-being of our members and the communities in which they live. Capital Blue Cross is an independent licensee of the Blue Cross Blue Shield Association. We are an equal opportunity/affirmative action employer and do not discriminate on the basis of race, color, religion, national origin, gender, sexual orientation, gender identity, age, genetic information, physical or mental disability, veteran status, or marital status, or any other status protected by applicable law.

Base pay is influenced by several factors including a candidate’s qualifications, relevant experience, and anticipated contributions to meet the needs of the business, along with internal pay equity and external market driven rates. The salary range displayed has not been adjusted for geographical location. This range has been created in good faith based on information known to Capital Blue Cross at the time of posting and may be modified in the future. Capital Blue Cross offers a comprehensive benefits packaging including Medical, Dental & Vision coverage, a Retirement Plan, generous time off including Paid Time Off, Holidays, and Volunteer time off, an Incentive Plan, Tuition Reimbursement, and more. 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.” This licensed clinical position is part of the Utilization Management department and is 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. Collaboration within and across departments and operating professionally and efficiently within the framework of established policies and procedures is essential.

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 and applying approved medical necessity criteria to determine medical necessity and appropriateness of the service requested. 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.