Clinical Reviewer, Behavioral Health

About the role

Point32Health is a leading not-for-profit health and well-being organization dedicated to delivering high-quality, affordable healthcare. Serving nearly 2 million members, Point32Health builds on the legacy of Harvard Pilgrim Health Care and Tufts Health Plan to provide access to care and empower 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 all of our colleagues, which helps us to provide service with empathy and better understand and meet the needs of the communities where we serve, live, and work.

Responsibilities

• 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 all 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.
• Concurrent 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 all 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

• Education Required (minimum): BS Nursing; LICSW, LMHC, or other behavioral health profession qualified to practice independently.
• 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 McKesson’s InterQual Clinical Screening Criteria.
• Preferred: 3 years in a managed care environment in managed care systems and operations.
• Skills: Ability to work cooperatively as a team member across multiple levels within 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, instant messaging, thin client, soft phone, or others; Proficiency with or ability to learn technology-based programs such as Microsoft Office Word and Excel; other programs as needed.