Clinical Reviewer, BH outpatient services

About the role

Point32Health is a leading not-for-profit health and well-being organization dedicated to delivering high-quality, affordable healthcare. Serving nearly 2 million members, Point32Health 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. We enjoy the important work we do every day in service to our members, partners, colleagues and communities. Learn more about who we are at Point32Health . 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 Point32Health 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 Review of all assigned prior authorization requests including but not limited to inpatient admissions, specialty referrals, outpatient procedures, VNA or outpatient therapies as specified in the prior authorization list using specified clinical criteria sets. Concurrent review of Behavior Health Services Identification and determination of benefit coverage for behavioral health coverage requests. Identifies and determines medical necessity of out of network requests for services. Effective communication with the Medical Director, regarding identified variances for specific members according to criteria utilized for medical review. Professional growth and development through self-directed learning activities and/or involvement in professional, civic, and community organizations Ongoing referrals to and interactions with the case management team to ensure efficient and safe care transitions and member access to supportive programs and services Works collaboratively with external providers to facilitate member access to high quality cost effective behavioral health services Adheres to all regulatory and contractual requirements Participates in department projects and special assignments as needed. Attends scheduled meetings, training session in both classroom and computer-based required training sessions. Assist in development and updating of department workflows. Other projects and duties as assigned. 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. Preferred: Experience (minimum years required): Required (minimum): 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. Preferred: 3 years in a managed care environment in managed care systems and operations. Skill Requirements Ability to work cooperatively as a team m