Behavioral Health Outpatient Utilization Management Reviewer # 26-17647

Key Responsibilities

• Carry out benefit coverage reviews and utilization management for behavioral health services according to regulatory guidelines and Enterprise contract requirements.
• Affirm compliance with regulatory requirements, organizational timelines, productivity standards, and authorization processes.
• Determine benefit coverage, medical necessity, and out-of-network service eligibility for behavioral health requests.
• Collaborate with providers, UM Support staff, Medical Directors, and Case Management teams to facilitate appropriate care, safe transitions, and member access to services.
• Communicate clinical variances, authorization decisions, and recommendations to relevant stakeholders.
• Participate in department initiatives by contributing to projects, workflow improvements, required meetings, and training sessions.
• Perform additional duties and special assignments as needed.

Qualifications/ Education

• Current unrestricted Massachusetts license in a behavioral health area of practice.
• Bachelor’s degree in Nursing, LICSW, LMHC, or another independently licensed behavioral health profession.
• Direct clinical practice experience within the candidate's credentialed discipline.
• Health Plan experience performing Utilization Review activities.
• Strong knowledge of Utilization Management and Care Management principles.
• Experience using McKesson InterQual Clinical Screening Criteria.

About US Tech Solutions

US Tech Solutions is a global staff augmentation firm providing a wide range of talent on-demand and total workforce solutions. To know more about US Tech Solutions, please visit www.ustechsolutions.com. US Tech Solutions is an Equal Opportunity Employer.