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It’s an exciting time to join the WellSense Health Plan, a growing regional health insurance company with a 25-year history of providing health insurance that works for our members, no matter their circumstances.

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.

Our Investment in You:

·       Full-time remote work

·       Competitive salaries

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.

·       In rotation with other BH UM clinicians, provide on-call weekend and holiday support for members that are ED boarding and manage urgent authorization needs.

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 or Bachelor’s degree in Nursing.

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:

·     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.