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Job description
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 us.
nResidency in or relocation to Louisiana is preferred for all positions.
nApplicants must be authorized to work for Louisiana Blue in the United States without employer-sponsored immigration support. Louisiana Blue will not provide current or future employment-based immigration sponsorship or other immigration support for this opportunity, including H-1B, L-1, O-1, H-1B1, E-3, TN, or J-1 sponsorship or F-1 OPT/STEM OPT/CPT support. Applicants who would require such sponsorship or employer support during their employment should not pursue this opportunity.
nPOSITION PURPOSE
nThe Behavioral Health Utilization Reviewer is responsible for conducting clinical reviews of behavioral health service requests, claims, and appeals to confirm medical necessity and appropriateness of care. The reviewer applies evidence-based criteria including InterQual and/or medical policy and collaborates with the Behavioral Health Medical Director for complex cases and requests that do not meet criteria for approval. This role does not make adverse determinations based on medical necessity. This role also involves gathering information from and communicating decisions to providers and members in a clear, timely, and professional manner.
nHow You Contribute to the Company's Mission In This Role
nnnReview pre-authorization requests, concurrent reviews, and retrospective claims for behavioral health services.
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nnApply clinical guidelines (e.g., InterQual, medical policy) to document medical necessity.
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nnRefer cases that do not meet criteria to the Psychiatric Medical Director for secondary review.
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nnReview and support the appeals department in reviewing provider and member appeals in accordance with regulatory timelines.
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nnInteracts with BH care providers as necessary to discuss level of care and/or service decisions.
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nnDocument clinical decisions and rationale in the utilization management system.
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nnCommunicate determinations to providers and members via phone and written correspondence.
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nnAnalyze BH member data to improve quality and appropriate utilization of services
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nnCollaborate with internal departments including Case Management, Quality, and Provider Relations.
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nnMaintain compliance with state, federal, and accreditation requirements (e.g., CMS, NCQA, URAC).
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nnParticipate in audits, training, and quality improvement initiatives.
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n nRequired Qualifications
nnnBachelor's degree in nursing, healthcare, or a related field OR master's degree in social work, counseling, or behavioral health
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nnRN license in Louisiana can replace the Bachelor's Degree -OR- LPN license in Louisiana + 2 years of related experience can replace the Bachelor's degree
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nnAt least 3 years of clinical or patient care experience in behavioral health
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nnMust have one of the following licenses: LPC, PLPC, LCSW, LMFT, LMSW, LPN, or RN
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nnStrong clinical assessment and critical thinking
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nnExcellent communication and teamwork
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nnGood understanding of behavioral health conditions and treatments
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nnAble to work independently and follow policies
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n nPreferred Qualifications
nnnExperience in a managed care or health insurance setting
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nnFamiliarity with CPT codes and billing practices.
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nnExperience working with Medicare and Commercial populations
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nnProficiency in electronic health records and case management systems
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n nThe Physical Demands described here are representative of those that must be met by an employee to successfully perform the Accountabilities and Essential Functions of the job. Reasonable accommodations may be made to enable an individual with disabilities to perform the essential functions
nnnPerform other job-related duties as assigned, within your scope of responsibilities.
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nnJob duties are performed in a normal and clean office environment with normal noise levels.
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nnWork is predominately done while standing or sitting.
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nnThe ability to comprehend, document, calculate, visualize, and analyze are required.
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n nAn Equal Opportunity Employer
nAll internal employees please apply through Workday Careers.
nPLEASE USE A WEB BROWSER OTHER THAN INTERNET EXPLORER IF YOU ENCOUNTER ISSUES (CHROME, FIREFOX, SAFARI)
nAdditional Information
nPlease be sure to monitor your email frequently for communications you may receive during the recruiting process. Due to the high volume of applications we receive, only those most qualified will be contacted. To monitor the status of your application, please visit the "My Applications" section in the Candidate Home section of your Workday account.
nIf you are an individual with a disability and require a reasonable accommodation to complete an application, please contact for assistance.
nIn support of our mission to improve the health and lives of Louisianians, we encourage the good health of its employees and visitors. We want to ensure that our employees have a work environment that will optimize personal health and well-being. Due to the acknowledged hazards from exposure to environmental tobacco smoke, and in order to promote good health, our company properties are smoke and tobacco free.
nWe perform background and pre-employment drug screening after an offer has been extended and prior to hire for all positions. As part of this process records may be verified and information checked with agencies including but not limited to the Social Security Administration, criminal courts, federal, state, and county repositories of criminal records, Department of Motor Vehicles and credit bureaus. Pursuant with sec 1033 of the Violent Crime Control and Law Enforcement Act of 1994, individuals who have been convicted of a felony crime involving dishonesty or breach of trust are prohibited from working in the insurance industry unless they obtain written consent from their state insurance commissioner.
nAdditionally, we are a Drug Free Workplace. A pre-employment drug screen will be required and any offer is contingent upon satisfactory drug testing results.
nJOB CATEGORY: Healthcare/Pharmacy Services
Worksite address
baton rouge, LA, 70873, US
Who can apply
Review the original listing for work authorization, qualifications and employer requirements.