Behavioral Health Utilization Manager (temporary)

Category Clinical Job Location Remote Tracking Code 2015749 Position Type Temporary 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 pref…