Clinical Reviewer

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. 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. Learn more about who we are at Point32Health. Job Summary Under the supervision of the Utilization Management Supervisor, the Behavioral Health (BH) Utilization Management (UM) Clinician is responsible for conducting benefit coverage reviews and utilization management according to applicable regulatory guidelines and Enterprise contract requirements. The BH UM Clinician works collaboratively with the Behavioral Health leadership within the Behavioral Health department and other appropriate Point32Health staff to identify and address opportunities to improve service, reduce administrative cost, ensure clinically appropriate delivery of benefit covered services, and support department and organizational business goals. The UM BH Clinician escalates urgent issues and concerns that could potentially impact member needs, program compliance and or acute situations that pose risk. The UM BH Clinician must be committed to clinical and service excellence, including demonstrating the behaviors that support teamwork, collaboration, and professionalism. The BH UM clinician works under the direction of the UM Supervisor and in collaboration with the BH Operation Manager to ensure ongoing competency and learning needs are met that they are performing to applicable regulatory and clinical requirements. 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 McKesson’s 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 $80,389.62 -$120,584.44 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 and benefits remains in the Company's sole discretion and may be modified at the Company’s sole discretion, consistent with the law. 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 We 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. #J-18808-Ljbffr