Utilization Management Clinician, Behavioral Health (Boston area)

We’re seeking Utilization Management Clinicians to join our behavioral health team! In this role, you will work to promote the well-being of our members by assessing, collaborating with providers, monitoring and coordinating care.

Be a part of a mission driven company and work alongside passionate, caring and collaborative team members. If you are motivated to make a difference in people’s lives and want to play a role in transforming how healthcare is delivered, we invite you to check out the opportunity below and apply today.

Position will be telework, and will require travel to visit our members, primarily at the providers location.

The Utilization Management Clinician applies approved medical necessity criteria to authorize and evaluate appropriate Behavioral Health (BH) services with providers for inpatient and diversionary levels of care. The clinician functions as a liaison between BMCHP inpatient and diversionary BH providers related to the authorization processes, continued stay decisions, discharge planning and transitions of care.

Key Functions/Responsibilities:
– Conducts utilization reviews (prior authorization, concurrent review and discharge planning) of all BH levels of care through the application of BMCHP approved BH criteria to determine medical necessity and equitable administration of benefits.
– Provides and summarizes clinical information to supervisors and other providers to ensure appropriate member care coordination and service delivery.
– Involved in ensuring member compliance with aftercare services through coordination with providers and internal staff for outreach to member.
– Anticipates member’s post discharge needs and coordinates and authorizes discharge planning services.
– In an accurate, complete, and timely fashion, enters data, utilizing systems software tools and applications. Independently performs quality checks for accuracy.
– Identifies members who could benefit from care management, or Intensive Care Management (ICM), according to established criteria.
– In all activities works to ensure linkage and integration of behavioral health and medical care. This includes both member-based activities and work with contracted – ACOs and agencies as part of community-based care management.
– Documents clinical assessments and coordination of care in the medical management information system in a timely manner that meets regulatory and accreditation standards.
– Facilitates all regulatory/accreditation correspondence.
– Meets departmental productivity and quality standards; maintains designated caseload volume and adheres to turn around times standards.
– Assists senior behavioral health management staff in ensuring the success of clinical network quality improvement initiatives.
– Provides high level of service and satisfaction to internal and external customers.
– After hours availability as needed.
– Perform other duties as assigned.

Qualifications:
– Degree in a behavioral health field such as psychology or social work, or a degree in nursing required.
– Current certificate or state licensure as an RN, LICSW, LMHC, Clinical Nurse Specialist, Licensed Psychologist or CADAC is required.
– Two or more years related experience in Mental Health, BH Case Management, and/or substance abuse treatment.
– Experience with Medicaid recipients and community services.
– Experience with prior authorization, utilization review, and/or discharge planning.
– Experience in a health plan or insurance environment.
– Experience with InterQual or other medical necessity criteria.

Position Description »