Remote Behavioral Health Utilization Manager - Outpatient

Wellsense-Health-Plan; Boston (MA); Hybrid; USD 70,000 - 101,000; Full time

Benefits offered by this job

Full-time remote work

Competitive salaries

Excellent benefits

Job summary

WellSense Health Plan in the Boston area is seeking a Behavioral Health Utilization Manager who will apply advanced clinical judgment to evaluate outpatient and non-24-hour behavioral health services and determine appropriate care for members.

You will collaborate with Medical Directors, coordinate care, document decisions clearly, participate in rounds, and support quality and regulatory compliance while maintaining rapid response to urgent authorization needs.

Qualifications

• Master's degree in Social Work, Psychology, Counseling, or related Behavioral Health field.
• Or Bachelor’s degree in Nursing.
• 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.

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.

Skills

Clinical decision-making

Critical thinking

Communication

Documentation

Collaboration

Crisis intervention

Education

MSW or related field

RN with BSN

Tools

Microsoft Office

Outlook

Excel

Job description

WellSense Health Plan in the Boston area is seeking a Behavioral Health Utilization Manager who will apply advanced clinical judgment to evaluate outpatient and non-24-hour behavioral health services and determine appropriate care for members.

You will collaborate with Medical Directors, coordinate care, document decisions clearly, participate in rounds, and support quality and regulatory compliance while maintaining rapid response to urgent authorization needs.