Behavioral Health Utilization Manager; Outpatient and Non-Diversionary Services) CBHI

It’s an exciting time to join the Well Sense 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.

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.

• Full-time remote work
• Competitive salaries
• Excellent benefits

• 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)

• 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.

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

• Active, unrestricted…