HNE Behavioral Health Utilization Management Reviewer

Baystate Health•Opportunity, WA

3d•Remote

About The Position

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.

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, including one or more of the following: Inpatient behavioral health, Outpatient or ambulatory behavioral health, Case management, Emergency psychiatric services, Diversionary levels of care
Candidate must hold professional license in MA in order to be considered.

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.
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.

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.
Participate in off-site visits with contracted behavioral health providers and facilities as needed.
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.