HNE Behavioral Health Utilization Management Reviewer

Baystate Health•Opportunity, WA

1d•Remote

About The Position

At Health New England, the Behavioral Health Utilization Management Reviewer helps ensure members receive timely, appropriate, and compassionate behavioral health services and are placed at an appropriate level of care. The role partners with providers, physicians, care managers, and community resources to review medical necessity, coordinate care, and support positive clinical, functional, and psychosocial outcomes. The position performs utilization management and care coordination activities intended to promote quality, cost-effective, evidence-based behavioral health care. The role reviews behavioral health services using nationally recognized clinical criteria; conducts pre-authorization, admission, concurrent, retrospective, and discharge reviews for inpatient and outpatient services; evaluates requested levels of care and treatment plans; obtains additional clinical information; and collaborates with physician reviewers on medical necessity determinations, denials, and complex cases. It also coordinates transitions of care, facilitates community and internal-program referrals, assists with appeals, participates in quality and departmental initiatives, and supports policy and procedure development. The reviewer maintains accurate, objective, timely documentation and ensures utilization management activities meet NCQA, DOI, and other regulatory requirements, including applicable timelines and quality standards. Onboarding and training take place at 1 Monarch Place in Springfield, Massachusetts. After successful completion of training and onboarding, the position is fully remote. Candidates must hold a professional license in Massachusetts.

Requirements

Master’s degree in social work (MSW) or equivalent behavioral health clinical education; the posting also lists a master’s degree as required.
Current Massachusetts licensure as one of the following: LICSW, LCSW, LMHC, Licensed Psychologist, or Registered Nurse (RN) with behavioral health experience.
Three to five years of behavioral health clinical experience in one or more of the following: inpatient behavioral health, outpatient or ambulatory behavioral health, case management, emergency psychiatric services, or diversionary levels of care.
Strong clinical assessment and critical thinking skills.
Excellent written and verbal communication skills.
Ability to prioritize multiple cases while meeting regulatory timelines.
Commitment to maintaining confidentiality and handling sensitive behavioral health information professionally.

Nice To Haves

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.
Experience using electronic utilization management or care management systems.

Responsibilities

Perform medical necessity utilization management and care coordination activities to 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 and 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.
Participate in off-site visits with contracted behavioral health providers and facilities as needed.
Maintain accurate, objective, and timely documentation supporting clinical decisions.
Ensure utilization management activities meet NCQA, DOI, and other regulatory requirements and support compliance with regulatory timelines and quality standards.
Collaborate with physician reviewers to ensure appropriate oversight of complex utilization management decisions.