BH Clinician (Utilization Management) at Horizon Blue Cross Blue Shield of New Jersey in Newark, New Jersey

Posted in Other 3 days ago.

Job Description:

Job Summary:

This position is responsible for performing behavioral health duties using established guidelines to ensure appropriate level of care as well as planning for the transition to the continuum of care. Performs duties and types of care management as assigned by management.


  • Assesses patient's behavioral health clinical need against established guidelines and/or standards to ensure that the level of care and length of stay of the patient are medically appropriate for inpatient stay.

  • Evaluates the necessity, appropriateness and efficiency of behavioral health medical services and procedures provided.

  • Coordinates and assists in implementation of plan for members.

  • Monitors and coordinates services rendered outside of the network, as well as outside the local area, and coordinates internally for negotiation of fees for such services as appropriate. Coordinates with patient, family, physician, hospital and other external customers with respect to the appropriateness of care from diagnosis to outcome.

  • Coordinates the delivery of high quality, cost-effective care supported by clinical practice guidelines established by the plan addressing the entire continuum of care.

  • Monitors patient's behavioral health medical care activities, regardless of the site of service, and outcomes for appropriateness and effectiveness.

  • Advocates for the member/family among various sites to coordinate resource utilization and evaluation of services provided.

  • Encourages member participation and compliance in the behavioral health case/disease management program efforts.

  • Documents accurately and comprehensively based on the standards of practice and current organization policies.

  • Interacts and communicates with multidisciplinary teams either telephonically and/or in person striving for continuity and efficiency as the member is managed along the continuum of care.

  • Understands fiscal accountability and its impact on the utilization of resources, proceeding to self-care outcomes.

  • Evaluates care by problem solving, analyzing variances and participating in the quality improvement program to enhance member outcomes.

  • Completes other assigned functions as requested by management.

The information above is intended to describe the general nature of the work being performed by each incumbent assigned to this position. This job description is not designed to be an exhaustive list of all responsibilities, duties, and skills required of each incumbent.


  • Requires a masters in a behavioral health related field or Nursing degree

  • Requires a minimum of two (2) years behavioral health clinical experience.

  • Behavioral health experience, preferably in a managed care setting, strongly preferred.

Additional licensing, certifications, registrations:

  • Active Unrestricted NJ LCSW, LMFT, LPC, RN License or Applied Behavior Analysis Certification Required

  • Applied Behavior Analysist Certification preferred


  • Prefers proficiency in the use of personal computers and supporting software in a Windows based environment, including MS Office products (Word, Excel, PowerPoint) and Lotus Notes; prefers knowledge in the use of intranet and internet applications.

  • Prefers working knowledge of case/care management principles.

  • Prefers working knowledge of principles of utilization management.

  • Prefers basic knowledge of health care contracts and benefit eligibility requirements.

  • Prefers knowledge of hospital structures and payment systems.

Skills and Abilities:

  • Analytical

  • Compassion

  • Interpersonal & Client Relationship Skills

  • Judgment

  • Listening

  • Planning/Priority Setting

  • Problem Solving

  • Team Player

  • Time Management

  • Written/Oral Communication & Organizational Skills

Travel % (If Applicable):

  • Forfield based positions, travel required 100%.

Horizon Blue Cross Blue Shield of New Jersey is an Equal Opportunity/Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran status or status as an individual with a disability and any other protected class as required by federal, state or local law. Horizon will consider reasonable accommodation requests as part of the recruiting and hiring process.

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