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Baystate Health

Advancing Care. Enhancing Lives.

Behavioral Health Utilization Management Reviewer

ReviewerGeneralFull TimeRemoteSeniorTeam 10,001+Since 1873H1B No SponsorCompany SiteLinkedIn

Location

Massachusetts

Posted

5 days ago

Salary

$89.6K - $121.8K / year

Seniority

Senior

Postgraduate Degree3 yrs expEnglish

Job Description

Behavioral Health Utilization Management Reviewer

Baystate Health

• 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. • Maintain accurate, objective, and timely documentation supporting clinical decisions.

Job 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.
  • 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.
  • Experience utilizing electronic utilization management or care management systems.

Benefits

  • Health insurance
  • Professional development opportunities
  • Paid time off

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