HNE Behavioral Health Utilization Management Reviewer

Baystatehealth; United States; Remote; USD 70,000 - 95,000; Full time

Job summary

Health New England is seeking a Behavioral Health Utilization Management Reviewer to ensure appropriate levels of care and coordinate services for members.

The role partners with providers and interdisciplinary teams to review medical necessity, support discharge planning, and facilitate access to community resources while upholding regulatory standards.

Qualifications

• Master's degree in social work (MSW) or equivalent behavioral health education.
• Current licensure as LICSW, LCSW, LMHC, Licensed Psychologist, RN with behavioral health experience in Massachusetts.
• 3–5 years of behavioral health clinical experience across inpatient or outpatient settings.

Responsibilities

• Perform medical necessity utilization management and care coordination for behavioral health.
• Review services for medical necessity using clinical criteria.
• Coordinate with providers and interdisciplinary teams for transitions of care.
• Assist with provider/member appeals related to behavioral health services.
• Support quality improvement initiatives and policy development.

Skills

Clinical assessment

Regulatory knowledge

Communication skills

Education

MSW or equivalent behavioral health education

Licensed in MA: LICSW/LCSW/LMHC/ RN with BH experience

Job description

At Health New England, we're committed to ensuring our members receive timely, appropriate, and compassionate behavioral health services.

As a Behavioral Health Utilization Management Reviewer, you'll play a vital role in ensuring our members are in the appropriate behavioral health level of care while helping providers understand the available resources across the continuum of care.

In this collaborative role, you'll partner with providers, physicians, care managers, and community resources to review medical necessity, coordinate care, and support positive clinical, functional, and psychosocial outcomes for our members. If you're a licensed behavioral health professional who thrives in a fast-paced environment and is passionate about improving the lives of individuals facing mental health and substance use challenges, we'd love to hear from you.

Responsibilities

As a Behavioral Health Utilization Management Reviewer, you will perform medical necessity utilization management and care coordination activities that promote quality, cost-effective, evidence-based behavioral health care.

Utilization Management

• Review behavioral health services for medical necessity using nationally recognized clinical criteria.
• Conduct pre-authorization, admission, concurrent, retrospective, and discharge reviews for inpatient and outpatient behavioral health services.
• Evaluate the appropriateness of requested levels of care and treatment plans.
• Collaborate with physician reviewers on cases requiring medical necessity determinations or denials.
• Research and obtain additional clinical information needed to support utilization management decisions.
• Assess requests for out-of-network services when appropriate.
• Proactively support discharge planning to ensure seamless transitions across the continuum of care.

Care Coordination

• Partner with providers, and interdisciplinary teams to coordinate behavioral health services and transitions of care.
• Facilitate referrals to community-based services and internal care management programs.
• Assist with provider and member appeals related to behavioral health services.
• Participate in quality improvement initiatives, clinical projects, and departmental workgroups.
• Contribute to the development and revision of departmental policies and procedures.
• Participate in off-site visits with contracted behavioral health providers and facilities as needed.

Regulatory Compliance & Documentation

• Ensure utilization management activities meet NCQA, DOI, and other regulatory requirements.
• Maintain accurate, objective, and timely documentation supporting clinical decisions.
• Collaborate with physician reviewers to ensure appropriate oversight of complex utilization management decisions.
• Support departmental compliance with regulatory timelines and quality standards.

Location:

Onboarding & Training at 1 Monarch Place in Springfield, MA. After successful completion of training/onboarding – this position is fully remote. Candidate must hold professional license in MA in order to be considered.

Required Qualifications

• Master's degree in social work (MSW) or equivalent behavioral health clinical education.
• Current licensure as one of the following in the state of Massachusetts: LICSW, LCSW, LMHC, Licensed Psychologist, Registered Nurse (RN) with behavioral health experience.
• Three to five years of behavioral health clinical experience, including one or more of the following: Inpatient behavioral health, Outpatient or ambulatory behavioral health, Case management, Emergency psychiatric services, Diversionary levels of care.

Preferred Knowledge & Skills

• Working knowledge of DSM-5 diagnostic criteria.
• Familiarity with ASAM Criteria and behavioral health medical necessity guidelines.
• Understanding of psychotropic medications and behavioral health treatment modalities.
• Knowledge of regional behavioral health resources and community services.
• Strong clinical assessment and critical thinking skills.
• Excellent written and verbal communication skills.
• Ability to prioritize multiple cases while meeting regulatory timelines.
• Experience utilizing electronic utilization management or care management systems.
• Commitment to maintaining confidentiality and handling sensitive behavioral health information with professionalism.

Education:

Masters Degree (Required)

Certifications:

• Licensed Clinical Social Worker - Other
• Licensed Independent Clinical Social Worker - State of Massachusetts
• Licensed Masters Social Worker - Other
• Licensed Mental Health Counselor - Other

Compensation

Note: The compensation range(s) in the table below represent the base salaries for all positions at a given grade across the health system. Typical, a new hire can expect a starting salary somewhere in the lower part of the range. Actual salaries may vary by position and will be determined based on the candidate's relevant experience. No employee will be paid below the minimum of the range. Pay ranges are listed as hourly for non-exempt employees and bas