Behavioral Health Utilization Management Reviewer
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Job Description
Behavioral Health Utilization Management Reviewer managing care coordination and medical necessity for behavioral health services while collaborating with providers. Ensuring quality and compliance in a fast-paced environment.
Responsibilities:
- Perform medical necessity utilization management and care coordination activities that promote quality, cost-effective, evidence-based behavioral health care.
- Review behavioral health services for medical necessity using nationally recognized clinical criteria.
- Conduct pre-authorization, admission, concurrent, retrospective, and discharge reviews for inpatient and outpatient behavioral health services.
- Evaluate the appropriateness of requested levels of care and treatment plans.
- Collaborate with physician reviewers on cases requiring medical necessity determinations or denials.
- Research and obtain additional clinical information needed to support utilization management decisions.
- Assess requests for out-of-network services when appropriate.
- Proactively support discharge planning to ensure seamless transitions across the continuum of care.
- Partner with providers, and interdisciplinary teams to coordinate behavioral health services and transitions of care.
- Facilitate referrals to community-based services and internal care management programs.
- Assist with provider and member appeals related to behavioral health services.
- Participate in quality improvement initiatives, clinical projects, and departmental workgroups.
- Contribute to the development and revision of departmental policies and procedures.
- Maintain accurate, objective, and timely documentation supporting clinical decisions.
Requirements:
- Master’s degree in social work (MSW) or equivalent behavioral health clinical education.
- Current licensure as one of the following in the state of Massachusetts : LICSW LCSW LMHC Licensed Psychologist Registered Nurse (RN) with behavioral health experience
- Three to five years of behavioral health clinical experience.
- Working knowledge of DSM-5 diagnostic criteria.
- Familiarity with ASAM Criteria and behavioral health medical necessity guidelines.
- Understanding of psychotropic medications and behavioral health treatment modalities.
- Knowledge of regional behavioral health resources and community services.
- Strong clinical assessment and critical thinking skills.
- Excellent written and verbal communication skills.
- Experience utilizing electronic utilization management or care management systems.
Benefits:
- Health insurance
- Professional development opportunities
- Paid time off
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