Clinical Reviewer, Behavioral Health

Behavioral Health Utilization Management Clinician

Point
32

Health is a leading not-for-profit health and well-being organization dedicated to delivering high-quality, affordable healthcare. Serving nearly 2 million members, Point
32

Health builds on the legacy of Harvard Pilgrim Health Care and Tufts Health Plan to provide access to care and empower healthier lives for everyone. Our culture revolves around being a community of care and having shared values that guide our behaviors and decisions. We've had a long-standing commitment to inclusion and equal healthcare access and outcomes, regardless of background; it's at the core of who we are.

We value the rich mix of backgrounds, perspectives, and experiences of all of our colleagues, which helps us to provide service with empathy and better understand and meet the needs of the communities where we serve, live, and work.

Job Summary

Under the supervision of the Utilization Management Supervisor, the Behavioral Health (BH) Utilization Management (UM) Clinician is responsible for conducting benefit coverage reviews and utilization management according to applicable regulatory guidelines and Enterprise contract requirements. The BH UM Clinician works collaboratively with the Behavioral Health leadership within the Behavioral Health department and other appropriate Point
32

Health staff to identify and address opportunities to improve service, reduce administrative cost, ensure clinically appropriate delivery of benefit covered services, and support department and organizational business goals. The UM BH Clinician escalates urgent issues and concerns that could potentially impact member needs, program compliance and or acute situations that pose risk. The UM BH Clinician must be committed to clinical and service excellence, including demonstrating the behaviors that support teamwork, collaboration, and professionalism.

The BH UM clinician works under the direction of the UM Supervisor and in collaboration with the BH Operation Manager to ensure ongoing competency and learning needs are met that they are performing to applicable regulatory and clinical requirements.

Job Description

Key Responsibilities/Duties – what you will be doing (top five):

• Adherence to established behavioral and administrative review guidelines and criteria
• Adherence to timelines, standards, and elements associated with organizational determinations and notifications
• 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
• Achievement of expected productivity goals

Qualifications – what you need to perform the job

Certification and Licensure

• Current unrestricted Massachusetts license in a behavioral health area of practice

Education

• Required (minimum): BS Nursing; LICSW, LMHC, or other behavioral health profession qualified to practice independently.

Skill Requirements

• Ability to work cooperatively as a team member across multiple levels within the organization
• Results orientation - strives to meet business goals
• Critical and Analytic thinking, i.e., must understand cause and effect as it relates to workflow design and implications to policies, procedures, and other departmental functions
• Comfort adapting to changes to business, market, regulatory, and strategic needs
• Ability to influence others and serve as role model
• Strong communications skills (formal and informal, written and verbal)
• Ability to handle multiple demands--must be able to balance multiple priorities
• Regard for confidential data and adherence to corporate compliance policy
• Proficiency with or ability to learn technology for initiating and participating in web/system-based communications: webinar, instant messaging, thin client, soft phone, or others
• Proficiency with or ability to learn technology-based programs such as Microsoft Office Word and Excel; other programs as needed

Working Conditions and Additional Requirements (include special requirements, e.g., lifting, travel):

• Fast paced office environment handling multiple demands.
• Must be able to exercise appropriate judgment when necessary and…