About the role
At Health New England, we're committed to ensuring our members receive timely, appropriate, and compassionate behavioral health services.
As a Behavioral Health Utilization Management Reviewer, you'll play a vital role in ensuring our members are in the appropriate behavioral health level of care while helping providers understand the available resources across the continuum of care.
In this collaborative role, you'll partner with providers, physicians, care managers, and community resources to review medical necessity, coordinate care, and support positive clinical, functional, and psychosocial outcomes for our members. If you're a licensed behavioral health professional who thrives in a fast-paced environment and is passionate about improving the lives of individuals facing mental health and substance use challenges, we'd love to hear from you.
Responsibilities
As a Behavioral Health Utilization Management Reviewer, you will perform medical necessity utilization management and care coordination activities that promote quality, cost-effective, evidence-based behavioral health care.
Utilization Management
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.
Care Coordination
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.
Participate in off-site visits with contracted behavioral health providers and facilities as needed.
Regulatory Compliance & Documentation
Ensure utilization management activities meet NCQA, DOI, and other regulatory requirements.
Maintain accurate, objective, and timely documentation supporting clinical decisions.
Collaborate with physician reviewers to ensure appropriate oversight of complex utilization management decisions.
Support departmental compliance with regulatory timelines and quality standards.
Location:
Onboarding & Training at 1 Monarch Place in Springfield, MA
After successful completion of training/onboarding – this position is fully remote. Candidate must hold professional license in MA in order to be considered.
Required Qualifications
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, including one or more of the following:
Inpatient behavioral health
Outpatient or ambulatory behavioral health
Case management
Emergency psychiatric services
Diversionary levels of care
Preferred Knowledge & Skills
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.
Ability to prioritize multiple cases while meeting regulatory timelines.
Experience utilizing electronic utilization management or care management systems.
Commitment to maintaining confidentiality and handling sensitive behavioral health information with professionalism.
Education:
Masters Degree (Required)Certifications:
Licensed Clinical Social Worker - Other, Licensed Independent Clinical Social Worker - State of Massachusetts, Licensed Masters Social Worker - Other, Licensed Mental Health Counselor - OtherCompensation
Note: The compensation range(s) in the table below represent the base salaries for all positions at a given grade across the health system. Typically, a new hire can expect a starting salary somewhere in the lower part of the range. Actual salaries may vary by position and will be determined based on the candidate's relevant experience. No employee will be paid below the minimum of the range. Pay ranges are listed as hourly for non-exempt employees and based on assumed full time commitment for exempt employees.
Minimum - Midpoint - Maximum
$89,606.00 - $103,001.00 - $121,804.00Equal Employment Opportunity Employer
Baystate Health is an Equal Opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, marital status, national origin, ancestry, age, genetic information, disability, or protected veteran status.
Originally posted on Himalayas