About Job

Your Role

The Behavioral Health Utilization Management team performs prospective utilization review for our members and correctly applies the guidelines for nationally recognized levels of care. They collaborate directly with the Member, Member's Family, and Interdisciplinary Care Team to achieve consensus and promote positive Member health outcomes through the assessment, planning, implementation, and evaluation of the Member’s Care Plan. The Licensed Clinician, Senior will report to the Manager, Behavioral Health Utilization Management. In this role you will be working with both the Utilization and Care Management teams, who provide utilization management, telephonic triage and care management assistance to members requesting access to Applied Behavioral Analysis (ABA) benefit. This role has a primary function of utilization management for our members seeking Behavioral Health Treatment (BHT).

Your Work

In this role, you will:

Perform prospective utilization reviews and first level determination for members using BSC evidenced based guidelines, policies and/or nationally recognized clinal criteria
Review Functional Behavioral Assessments (FBA) and Board Certified Behavior Analyst (BCBA) Assessments submitted by providers for adherence to BACB “best practice” guidelines
Gather clinical information and apply the appropriate clinical criteria/guideline, policy, and clinical judgment to render coverage determination/recommendation; prepare and present cases to Medical Director (MD) for medical director oversight and necessity
determination
Develop and review member centered documentation and correspondence reflecting determinations in compliance with regulatory and accreditation standards and identify potential quality of care issues, service or treatment delays and intervenes or as clinically appropriate
Act as a liaison with caregivers, providers, and the health care community to provide information to regarding community treatment resources, mental health managed care programs, company policies and procedures, and medical necessity criteria
Support team through consistent and successful caseload management and workload to achieve team goals, regulatory timelines, and accreditation standards
Recognize the members right to self-determination as it relates to the ethical principle of autonomy, including the members/family's right to make informed choices that may not promote the best outcomes, as determined by the healthcare team

Your Knowledge and Experience

Master’s degree in psychology or a related field
Possesses an active BCBA certification
At least 5 years of experience as a BCBA
Expert knowledge of Applied Behavior Analysis and Autism Spectrum Disorders
Considerable knowledge of Medi-Cal Managed Care
Demonstrated ability to deliver training to varied audiences and conduct effective meetings
Experience in a managed health care environment with regards to BHT services
Ability to identify problems and works towards problem resolution independently, seeking guidance as needed
Ability to represent the health plan in a professional and knowledgeable fashion
Ability to express ideas clearly in both written and oral communications
Ability to develop, organize, analyze, and implement processes and procedures
Proficiency with Microsoft applications including Word, Excel, Outlook, and Teams
Effective interpersonal skills

ABOUT THE TEAM
About Blue Shield of California

As of January 2025, Blue Shield of California became a subsidiary of Ascendiun. Ascendiun is a nonprofit corporate entity that is the parent to a family of organizations including Blue Shield of California and its subsidiary, Blue Shield of California Promise Health Plan; Altais, a clinical services company; and Stellarus, a company designed to scale healthcare solutions. Together, these organizations are referred to as the Ascendiun Family of Companies.

At Blue Shield of California, our mission is to create a healthcare system worthy of our family and friends and sustainably affordable. We are transforming health care in a way that genuinely serves our nonprofit mission by lowering costs, improving quality, and enhancing the member and physician experience.

To achieve our mission, we foster an environment where all employees can thrive and contribute fully to address the needs of the various communities we serve. We are committed to creating and maintaining a supportive workplace that upholds our values and advances our goals.

Blue Shield is a U.S. News Best Company to work for, a Deloitte U.S. Best Managed Company and a Top 100 Inspiring Workplace. We were recognized by Fair360 as a Top Regional Company, and one of the 50 most community-minded companies in the United States by Points of Light. Here at Blue Shield, we strive to make a positive change across our industry and communities – join us!

Our Values:

Honest. We hold ourselves to the highest ethical and integrity standards. We build trust by doing what we say we're going to do and by acknowledging and correcting where we fall short.
Human. We strive to listen and communicate effectively, showing empathy by understanding others' perspectives.
Courageous. We stand up for what we believe in and are committed to the hard work necessary to achieve our ambitious goals.

Our Workplace Model:

At Blue Shield of California and the Ascendiun Family of Companies, we believe in fostering a workplace environment that balances purposeful in-person collaboration with flexibility. As we continue to evolve our workplace model, our focus remains on creating spaces where our people can connect with purpose – whether working in the office or through a hybrid approach – by providing clear expectations while respecting the diverse needs of our workforce.

Two Ways of Working:

Hybrid (Default): Work from a business unit-approved office at least two (2) times per month (for roles below Director-level) or once per week (for Director-level roles and above). Exceptions:

o Member-facing and approved out-of-state roles remain remote.

o Employees living more than 50 miles from their assigned offices are expected to work with their managers on a plan for periodic office visits.

o For employees with medical conditions that may impact their ability to work in-office, we are committed to engaging in an interactive process and providing reasonable accommodations to ensure their work environment is conducive to their success and well-being.

On-Site: Work from a business unit-approved office an average of four (4) or more days a week.

Physical Requirements:

Office Environment - roles involving part to full time schedule in Office Environment. Based in our physical offices and work from home office/deskwork - Activity level: Sedentary, frequency most of work day.

Equal Employment Opportunity:

External hires must pass a background check/drug screen. Qualified applicants with arrest records and/or conviction records will be considered for employment in a manner consistent with Federal, State and local laws, including but not limited to the San Francisco Fair Chance Ordinance. All qualified applicants will receive consideration for employment without regards to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran status or disability status and any other classification protected by Federal, State and local laws.