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Point32Health

Point32Health is a leading not-for-profit health organization formed by a merger between Harvard Pilgrim Health Care and Tufts Health Plan. With the mission of

Clinical Reviewer, Behavioral Health

Location

Massachusetts

Posted

140 days ago

Salary

$76.1K - $114.2K / year

Seniority

Senior

Bachelor Degree3 yrs expEnglish

Job Description

Clinical Reviewer, Behavioral Health

Point32Health

• Conducting benefit coverage reviews and utilization management according to applicable regulatory guidelines and Enterprise contract requirements • Daily interactions with UM Support staff and providers to ensure clinical information and support are available and applicable to the review process • Appropriate prioritization of authorization requests • Review of all assigned prior authorization requests including but not limited to inpatient admissions, specialty referrals, outpatient procedures, VNA or outpatient therapies • Concurrent review of Behavior Health Services

Job Requirements

  • Current unrestricted Massachusetts license in a behavioral health area of practice
  • BS Nursing; LICSW, LMHC, or other behavioral health profession qualified to practice independently
  • Direct practice clinical experience in area of credential
  • Must demonstrate sound knowledge of utilization management and care management principles
  • Health Plan experience performing utilization review activities
  • Experience with McKesson’s InterQual Clinical Screening Criteria
  • 3 years in a managed care environment in managed care systems and operations.

Benefits

  • Medical, dental and vision coverage
  • Retirement plans
  • Paid time off
  • Employer-paid life and disability insurance with additional buy-up coverage options
  • Tuition program
  • Well-being benefits
  • Full suite of benefits to support career development, individual & family health, and financial health

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