Behavioral Health Utilization Management Clinician Reviewer

Who We Are

Point32Health is a leading health and wellbeing organization, delivering an ever-better personalized health care experience to everyone in our communities. At Point32Health, we are building on the quality, nonprofit heritage of our founding organizations, Tufts Health Plan and Harvard Pilgrim Health Care, where we leverage our experience and expertise to help people find their version of healthier living through a broad range of health plans and tools that make navigating health and wellbeing easier.

We enjoy the important work we do every day in service to our members, partners, colleagues and communities. To learn more about who we are at Point32Health, click here.

Job Summary

Provide behavioral health utilization review and care management in order to ensure timely and appropriate services for the membership while in Behavioral Health acute and intermediate levels of care and to ensure coordination of care. To facilitate coordination and integration of behavioral health, medical management, and case management services. KEY RESPONSIBILITIES: Conduct clinical concurrent and discharge reviews for behavioral health treatment requests. Evaluate clinical information to screen for medical necessity of behavioral health services and ensure members receive the most appropriate treatment based on their clinical presentation and needs. Consult with internal managers and physician advisors when it appears requests for services do not meet medical necessity criteria, and propose alternative plans of treatment. Work as a member of one of the Concurrent Review Team.

Key Responsibilities/Duties – what you will be doing

Coordinate the delivery of services to members throughout the continuum of care and interface with providers as needed to ensure appropriate services are being provided. Provide information to providers and members regarding behavioral health benefits and treatment resources. Provide telephonic triage and crisis intervention to callers. Interact with others in a professional, respectful manner that facilitates the treatment process.   Identify through proactive concurrent reviews high-risk/high cost complex members for internal case management, and make appropriate referrals. Collaborate closely with Integrated Care Management and Medical Management departments to ensure behavioral, medical and social care management interventions are integrated.   Provide back up for peers, including other teams within the Behavioral Health department   Identify opportunities for improvement and participate in development of action plans as needed   Participate in clinical activities, initiatives and projects to achieve Tufts Health Plans goals. Work collaboratively with other departments as appropriate.   Adhere to all department and regulatory standards, and ensure all workflow processes are completed within required timeframes. This includes, but is not limited to, standards for documentation of clinical information and authorizations of care.  

Qualifications – what you need to perform the job

JOB QUALIFICATIONS: KNOWLEDGE/SKILLS/ABILITIES   EDUCATION: (Minimum education & certifications required)

• Master’s degree in behavioral health related discipline (social work, counseling psychology or related field, nursing)
• Active unrestricted Massachusetts licensure to practice independently as behavioral health clinician (LICSW, LMHC, LMFT, PhD, PsyD)

  EXPERIENCE:  (Years of experience)

• Minimum of 2 years post-master’s direct clinical experience; 3-5 years preferred
• Experience with managed care and/or Medicaid a plus

  SKILL REQUIREMENTS: (Include interpersonal skills)

• Minimum of two years of experience in clinical settings providing direct client care.
• Solid understanding of the continuum of behavioral health levels of care.

·      Excellent interpersonal and communication skills. Able to build relationships with and respond to internal and external stakeholders at a variety of levels. Able communicate effectively verbally and electronically. ·      Excellent time management skills. Able to set priorities and complete work within timeframes.

• Ability to multitask, especially typing while simultaneously conducting utilization reviews.
• Proficiency with Microsoft applications, including Excel and Word
• Ability and willingness to work autonomously yet simultaneously interdependently on small to large teams.

High adaptability to an ever-changing managed care environment

Compensation & Total Rewards Overview

Commitment to Diversity, Equity, Inclusion, Accessibility (DEIA) and Health Equity

​Point32Health is committed to making diversity, equity, inclusion, accessibility and health equity part of everything we do—from product design to the workforce driving that innovation. Our Diversity, Equity, Inclusion, Accessibility (DEIA) and Health Equity team's strategy is deeply connected to our core values and will evolve as the changing nature of work shifts. Programming, events, and an inclusion infrastructure play a role in how we spread cultural awareness, train people leaders on engaging with their teams and provide parameters on how to recruit and retain talented and dynamic talent.  We welcome all applicants and qualified individuals, who will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, disability, age, or veteran status.

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