Clinical Reviewer, Behavioral Health

Who We Are

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. Weve had a long-standing commitment to inclusion and equal healthcare access and outcomes regardless of background; its 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.

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

Job Summary

Job Description

Key Responsibilities/Duties what you will be doing (top five):

• 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 what you need to perform the job

Certification and Licensure

• Current unrestricted Massachusetts license in a behavioral health area of practice

Education

• Required (minimum): BS Nursing; LICSW LMHC or other behavioral health profession qualified to practice independently.
• Preferred:

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 McKessons InterQual Clinical Screening Criteria.
• Preferred: 3 years in a managed care environment in managed care systems and operations.

Skill Requirements

• 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

Working Conditions and Additional Requirements (include special requirements e.g. lifting travel):

• Fast paced office environment handling multiple demands.
• Must be able to exercise appropriate judgment when necessary and work and communicate with customers in a telephonic office environment
• Must be able to work under normal office conditions and work from home as required.
• Work may require simultaneous use of a telephone/headset and PC/keyboard and sitting for extended durations.
• May be required to work additional hours beyond standard work schedule.

Disclaimer

The above statements are intended to describe the general nature and level of work being performed by employees assigned to this classification. They are not intended to be construed as an exhaustive list of all responsibilities duties and skills required of employees assigned to this position. Management retains the discretion to add to or change the duties of the position at any time.

Salary Range

Compensation & Total Rewards Overview

The annual base salary range provided for this position represents a range of salaries for this role and similar roles across the organization. The actual salary for this position will be determined by several factors including the scope and complexity of the role; the skills education training credentials and experience of the candidate; as well as internal equity. As part of our comprehensive total rewards program colleagues are also eligible for variable pay. Eligibility for any bonus commission benefits or any other form of compensation andbenefits remains in the Companys sole discretion and maybe modified at the Companys sole discretion consistent with the law.

Point32Health offers their Colleagues a competitive and comprehensive total rewards package which currently includes:

• Medical dental and vision coverage

• Retirement plans

• Paid time off

• Employer-paid life and disability insurance with additional buy-up coverage options

• Tuition program

• Well-being benefits

• Full suite of benefits to support career development individual & family health and financial health

For more details on our total rewards programs visit welcome all
All applicants are welcome and 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.

Scam Alert: Point32Health has recently become aware of job posting scams where unauthorized individuals posing as Point32Health recruiters have placed job advertisements and reached out to potential candidates. These advertisements or individuals may ask the applicant to make a payment. Point32Health would never ask an applicant to make a payment related to a job application or job offer or to pay for workplace equipment. If you have any concerns about the legitimacy of a job posting or recruiting contact you may contact