Behavioral Health Utilization Manager (temporary) - CBHI Experience

WellSense Health Plan

9d•$33 - $49•Remote

About The Position

It’s an exciting time to join the WellSense Health Plan, a growing regional health insurance company with a 25-year history of providing health insurance that works for our members, no matter their circumstances. Job Summary: The Behavioral Health Utilization Manager plays a critical role in ensuring the appropriate and effective delivery of mental health and substance use disorder services. This role serves as a key clinical decision-maker, exercising independent judgment and critical thinking in the evaluation of behavioral health service requests. This position is responsible for managing complex outpatient and non-24-hour diversionary cases, applying clinical expertise to ensure appropriate, timely, and effective care. The role requires a proactive and analytical approach to service delivery, with a focus on clinical quality and compliance.

Requirements

Master's degree in Social Work, Psychology, Counseling, or a related Behavioral Health field or Bachelor’s degree in Nursing.
5-7 years of experience in a health insurance environment with a focus on behavioral health.
Demonstrated expertise in utilization management and medical necessity determinations.
Active, unrestricted independent licensure in MA and/or NH in one of the following: LICSW, LMHC, or LMFT or RN
Exceptional verbal and written communication skills, with the ability to collaborate effectively across all organizational levels and with external partners.
Strong organizational and time management abilities, with a focus on meeting deadlines and managing competing priorities.
Capacity to thrive in a fast-paced environment, balancing multiple responsibilities while maintaining accuracy and efficiency.
Proficiency in Microsoft Office applications, particularly Outlook, Word, and Excel, along with experience in data management systems.
Superior analytical and problem-solving skills with a keen attention to detail.
Consistent and reliable attendance is an essential job requirement.

Nice To Haves

Experience working with Child and Adolescent Behavioral Health Services and/or Substance Use Disorder Services.
Familiarity with managed care principles and regulatory compliance requirements.

Responsibilities

Use advanced clinical judgment and critical thinking to evaluate outpatient and non-24-hour behavioral health services, determining the appropriateness of care based on individual member needs, clinical presentations, and professional standards.
Collaborate with Medical Directors when clinical complexity requires further review, ensuring decisions align with clinical best practices and organizational values.
Identify members who may benefit from enhanced care coordination or specialized interventions and initiate appropriate referrals to internal programs.
Ensure accurate, timely, and well-reasoned documentation of clinical decisions in accordance with operational standards and regulatory expectations.
Provide clear, thoughtful communication to internal and external stakeholders, helping resolve questions or concerns with clinical insight in a timely manner.
Participate in clinical rounds and interdisciplinary case discussions to support collaborative care planning and cross-functional learning.
Represent the organization with external partners, including providers and state agencies, conveying clinical insight and ensuring organizational compliance.
Monitor clinical trends for potential indicators of Fraud, Waste, and Abuse (FWA), and take appropriate action when concerns are identified.
Partner with leadership and the BH Medical Director to evaluate existing processes and support initiatives aimed at improving quality and operational efficiency.
Provide crisis intervention support using clinical judgment to de-escalate situations and assist members in stabilizing their conditions.
Uphold all organizational policies, professional standards, and compliance requirements.
Contribute to special projects and organizational initiatives as assigned by senior leadership, offering insight and subject matter expertise.
In rotation with other BH UM clinicians, provide on-call weekend and holiday support for members that are ED boarding and manage urgent authorization needs.
Providing Network Management in collaboration with other MCEs within Massachusetts for CBHI Providers (may require some travel within Massachusetts)