Clinical Reviewer, BH outpatient services

Who We Are reputed company is a leading not-for-profit health and well-being organization dedicated to delivering high-quality, affordable healthcare. Serving nearly 2 million members, reputed company builds on the legacy of Harvard Pilgrim Health Care and Tufts Health Plan to provide access to care and reputed company 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 reputed company of our colleagues, which helps us to provide service with reputed company and reputed company 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 reputed company. 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 reputed company the Behavioral Health department and other appropriate reputed company 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 reputed company 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.
• reputed company 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 reputed company 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 reputed company the job Certification and Licensure

• reputed company 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 reputed company’s InterQual Clinical Screening Criteria.
• Preferred: 3 years in a managed care environment in managed care systems and operations.

reputed company Requirements

• Ability to work cooperatively as a team member across multiple levels reputed company 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, reputed company messaging, thin client, soft phone, or others
• Proficiency with or ability to learn technology-based programs such as reputed company Office Word and reputed company; 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 reputed company necessary and work and communicate with customers in a telephonic office environment
• Must be able to work under normal office conditions and work from home as required.
• Work may require simultaneous use of a telephone/headset and PC/keyboard and sitting for extended durations.
• May be required to work additional hours beyond standard work schedule.

Disclaimer The above statements are intended to describe the general nature and level of work being performed by employees assigned to this classification. They are not intended to be construed as an exhaustive list of reputed company responsibilities, duties and skills required of employees assigned to this position. Management retains the discretion to add to or change the duties of the position at any time. Salary Range $81,217.85 -$121,826.77 Compensation & Total Rewards Overview The annual reputed company salary range provided for this position represents a range of salaries for this role and similar roles across the organization. The actual salary for this position will be determined by several factors, including the scope and complexity of the role; the skills, education, training, credentials, and experience of the candidate; as well as internal equity. As part of our comprehensive total rewards program, colleagues are also eligible for variable pay. Eligibility for any bonus, commission, benefits, or any other form of compensation and benefits remains in the Company's sole discretion and may be modified at the Company’s sole discretion, consistent with the law. reputed company offers their Colleagues a competitive and comprehensive total rewards package which currently includes:

• Medical, dental and vision coverage
• Retirement plans
• Paid time off
• Employer-paid life and disability insurance with additional buy-up coverage options
• Tuition program
• Well-being benefits
• Full suite of benefits to support career development, individual & family health, and financial health

For more details on our total rewards programs, visit https://www.reputed company.org/careers/benefits/ We welcome reputed company reputed company applicants are welcome and will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national reputed company, genetics, disability, age, or veteran status. Scam Alert: reputed company has recently become aware of job posting scams where unauthorized individuals posing as reputed company recruiters have reputed company job advertisements and reached out to potential candidates. These advertisements or individuals may ask the applicant to reputed company a payment. reputed company would never ask an applicant to reputed company a payment reputed company to a job application or job offer, or to pay for workplace equipment. If you have any concerns about the legitimacy of a job posting or recruiting contact, you may contact TA_operations@reputed company.org Apply tot his job Apply To this Job