Clinical Reviewer, Behavioral Health
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Job Description
Behavioral Health UM Clinician conducting benefit coverage reviews and managing utilization for Point32Health. Collaborating with leadership to improve service and ensure compliance with clinical requirements.
Responsibilities:
- Conducting benefit coverage reviews and utilization management according to applicable regulatory guidelines and Enterprise contract requirements
- Work collaboratively with the Behavioral Health leadership within the Behavioral Health department and other appropriate Point32Health staff
- Identify and address opportunities to improve service, reduce administrative cost
- Ensure clinically appropriate delivery of benefit covered services
- Support department and organizational business goals
- Escalate urgent issues and concerns that could potentially impact member needs
Requirements:
- Current unrestricted Massachusetts license in a behavioral health area of practice
- BS Nursing; LICSW, LMHC, or other behavioral health profession qualified to practice independently
- Direct practice clinical experience in area of credential
- Must demonstrate sound knowledge of utilization management and care management principles
- Health Plan experience performing utilization review activities
- Experience with McKesson’s InterQual Clinical Screening Criteria
- Ability to work cooperatively as a team member across multiple levels within the organization
- Results orientation - strives to meet business goals
- Critical and Analytic thinking
- Comfort adapting to changes to business, market, regulatory, and strategic needs
- Ability to influence others and serve as role model
- Strong communications skills
- Ability to handle multiple demands
- Regard for confidential data and adherence to corporate compliance policy
- Proficiency with or ability to learn technology for initiating and participating in web/system-based communications
- Proficiency with or ability to learn technology-based programs such as Microsoft Office Word and Excel; other programs as needed
Benefits:
- Medical, dental and vision coverage
- Retirement plans
- Paid time off
- Employer-paid life and disability insurance with additional buy-up coverage options
- Tuition program
- Well-being benefits
- Full suite of benefits to support career development, individual & family health, and financial health
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