Beacon Health Options is proud to be an Equal Opportunity and Affirmative Action Employer as well as Drug Free and Tobacco Free Work Environment. EOE/AA/M/F/Veterans/Disabled.
Position Location: MA - Boston AAP Reporting Location: MA - Boston (MBHP) ID: 50953 Job Family: Clinical, Licensed Functional Area: CLINICAL OPERATIONS FTE Status: Full time Scheduled Weekly Work Hrs: 40 Workday Schedule: Weekdays Only Workday Start Time: 8:30 AM Workday End Time: 5:00 PM Variable Work Schedule:
ABOUT THE POSITION We are currently seeking a dynamic Utilization Review Clinician to join our team at our office in Boston, MA. The Utilization Review Clinician will be responsible for performing utilization review and initial authorization determination of mental health and substance use services provided in inpatient, diversionary and outpatient care settings. She/he applies Beacon's medical necessity level of care criteria and ensures that all Beacon policy and procedure guidelines, external regulatory requirements and URAC/NCQA accreditation standards are met.
Position Responsibilities: • Performs telephonic care review and authorization determinations for prospective, concurrent and discharge review with psychiatric and substance treatment facilities as assigned • Determines appropriate level of care related to mental health and substance use treatment for members based on Beacon medical necessity level of care criteria • Consults with Beacon Physician Advisors (PA) when requests for services do not meet medical necessity criteria • Interacts with Physician Advisors to discuss clinical/authorization questions, alternative treatment options and concerns regarding specific cases • Provides information to members and providers regarding mental health and substance abuse benefits and community treatment resources • Identifies and refers high risk members to care management. • Recognizes quality of care issues and reports them appropriately through internal and external processes. • Interacts with providers and facilities in a professional, respectful manner • Complies with all Beacon policy guidelines, external regulatory requirements and URAC/NCQA accreditation standards. • Demonstrates thorough understanding of product lines and benefit structure for all contracts assigned • Assists with NCQA, URAC and other QI initiatives • Other duties as assigned
Position Requirements: Education : Master's degree or higher in a health related field and licensure as a RN or behavioral health professional. Licensure : Current, valid and unrestricted licensure for practice required with proof on date of hire. Re-verification will take place no less than every 3 years. Relevant Work Experience:
Minimum of 2 years behavioral health experience.
Medicare, Medicaid and Managed care experience preferred.
Knowledge, Skills & Abilities :
Case Managers must practice within the scope of their license. Non-certifications may not be issued on initial review, and always require consultation with a Physician or Psychologist Advisor.
Keen attention to detail.
Able to multitask with ease.
Desire to continually improve problem resolution skills.
Team player with an ability to work under pressure.
Ability to remain objective in all dealings with customers and maintain professional attitude at all times.
Ability to prioritize tasks and accomplish them in a timely fashion
Beacon Health Options is a health improvement company that serves 45 million individuals across all 50 states and the United Kingdom. On behalf of employers, health plans and government agencies, we manage innovative programs and solutions that directly address the challenges our behavioral health care system faces today. A national leader in the fields of mental and emotional wellbeing, recovery ...and resilience, employee assistance, and wellness, Beacon Health Options helps people make the difficult life changes needed to be healthier and more productive. Partnering with a network of providers nationwide, Beacon Health Options helps people take important steps in the right direction. We help them live their lives to the fullest potential. Visit www.beaconhealthoptions.com for more information.