Job Summary:
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.
Key Responsibilities:
- 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.
Potential Additional Responsibilities
- Providing Network Management in collaboration with other MCEs within Massachusetts for CBHI Providers (may require some travel within Massachusetts)
Qualifications:
Educational Requirements:
- Master's degree in Social Work, Psychology, Counseling, or a related Behavioral Health field.
Experience:
- 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.
Preferred Qualifications:
- Experience working with Child and Adolescent Behavioral Health Services and/or Substance Use Disorder Services.
- Familiarity with managed care principles and regulatory compliance requirements.
Licensure and Certification:
- Active, unrestricted independent licensure in Massachusetts and/or New Hampshire in one of the following: LICSW, LMHC, or LMFT.
- For ABA UM Position Only: Must hold an active Board Certified Behavior Analyst (BCBA) credential. Additional independent licensure (LICSW, LMHC, LMFT) is preferred.
- Core Competencies:
- Exceptional verbal and written communication skills, with the ability to collaborate effectively across all organizational levels and with external partners.
- Strong organizational and time management abilities, with a focus on meeting deadlines and managing competing priorities.
- Capacity to thrive in a fast-paced environment, balancing multiple responsibilities while maintaining accuracy and efficiency.
- Proficiency in Microsoft Office applications, particularly Outlook, Word, and Excel, along with experience in data management systems.
- Superior analytical and problem-solving skills with a keen attention to detail.
Work Environment and Physical Demands:
- Primarily remote role with periodic travel to the Charlestown, MA office for team meetings and training sessions.
- Additional travel within Massachusetts may be required for individuals with CBHI Network Management expectations.
- Dynamic and fast-paced work setting requiring adaptability and resilience.
- Minimal physical exertion required; standard office tasks such as typing and phone use.
- Consistent and reliable attendance is an essential job requirement.
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