Advancing Care. Enhancing Lives.
Behavioral Health Utilization Management Reviewer
Location
Massachusetts
Posted
5 days ago
Salary
$89.6K - $121.8K / year
Seniority
Senior
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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