Behavioral Health Clinical Lead

4 weeks ago

Canton, United States Point32Health Full time

Job Summary

Behavioral Health Utilization Management subject matter expert that ensures timely and appropriate services for Point32Health membership, across all lines of business. Under supervision of the Clinical Manager, this position provides training, coaching, and mentoring on both the group and individual levels to Behavioral Health UM Staff for Outpatient or Inpatient services. This position also supports the UM team on issues related to compliance, quality, and reporting.

 

Key Responsibilities/Duties – what you will be doing

  • Subject Matter Expert for at least two lines of business (could include: Commercial, Medicaid, Medicare, Duals, Direct), and at least 2 clinical systems (MHK, eCare/Jiva, CaseTrakker) is an internal resource for all Point32Health lines of business. Provide training, coaching, and mentoring on Outpatient or Inpatient Services. Collaborate with the Care Management and Medical Management departments as needed to ensure behavioral, medical, and social care management interventions are integrated.
  • Conduct clinical precertification, continued stay and discharge reviews for behavioral health treatment requests. Evaluate clinical information to screen for medical necessity of behavioral health services and ensure members receive the most appropriate treatment based on their clinical presentation and needs. Coordinate plans for additional treatment as needed. Consult with internal managers and physician advisors when it appears requests for services do not meet medical necessity criteria and propose alternative plans of treatment.
  • Coordinate the delivery of services to members throughout the continuum of care and interface with providers as needed to ensure appropriate services are being provided.
  • With support of manager, develop expertise related to compliance, quality, and reporting. Document and/or update BH UM processes and prepares reports as needed for compliance, quality, or reporting needs.
  • Consult with providers to assist members with transportation, employment and daily living needs as they relate to individualized behavioral health treatment plans by making appropriate internal case management referrals.
  • Provide information to providers and members regarding behavioral health benefits and treatment resources. Provide telephonic triage and crisis intervention to callers. Interact with others in a professional, respectful manner that facilitates the treatment process.
  • Provide back up for managers/supervisors and BH UM clinicians, including other teams within the Behavioral Health department Identify opportunities for improvement related to quality and compliance, as well as streamlining of processes. Participate in development of action plans as needed.
  • Participate in clinical activities, initiatives, and projects to achieve Tufts Health Plans goals. Work collaboratively with other departments as appropriate.

 

  • Adhere to all department and regulatory standards, review and understand all department and company Policies & Procedures and

 

  • Represent Point32Health (Tufts Health Plan and/or Harvard Pilgrim Health Care) at internal and external meetings with various stakeholders, for example: network management activities, DMH Emergency Department Boarding meetings, or provider representatives.
  • All other duties as assigned.

 

Qualifications – what you need to perform the job

EDUCATION: (Minimum education & certifications required)

  • Master’s degree in behavioral health related discipline (social work, counseling psychology or related field, nursing)
  • Active unrestricted Massachusetts licensure to practice independently as a behavioral health clinician (LICSW, LMHC, LMFT, RN, PhD, PsyD)

 

EXPERIENCE: (Years of experience)

  • Minimum of 3-5 years post-master’s clinical experience; with 3 years of BH UM experience
  • Experience with managed care and senior products is preferable

 

SKILL REQUIREMENTS: (Include interpersonal skills)

  • Minimum of two years of experience in clinical settings providing direct client care.
  • Solid understanding the continuum of behavioral health levels of care.
  • Demonstrated understanding and proficiency in the principles, concepts and techniques of managed care and utilization management
  • Strong understanding of at least 2 separate lines of business
  • Excellent interpersonal and communication skills. Able to build relationships with and respond to internal and external stakeholders at a variety of levels. Able communicate effectively verbally and electronically.
  • Excellent time management skills, and ability to multi-task. Able to set priorities and complete work within timeframes, even when turnaround times are short.
  • Detail-oriented, with interest in and ability to manage quality, compliance and reporting projects
  • Able to use various sources of communication such as written, verbal and non-verbal communication to effectively impart information to others.
  • Ability and willingness to work autonomously yet simultaneously interdependently on small to large teams.
  • High adaptability to an ever-changing managed care environment.
  • Proficiency with Microsoft applications, including Excel, Word and PowerPoint


Commitment to Diversity, Equity & Inclusion

Point32Health is committed to making diversity, equity, and inclusion part of everything we do—from product design to the workforce driving that innovation. Our DEI strategy is deeply connected to our core values and will evolve as the changing nature of work shifts. Programming, events, and an inclusion infrastructure play a role in how we spread cultural awareness, train people leaders on engaging with their teams and provide parameters on how to recruit and retain talented and dynamic talent. We welcome all applicants and qualified individuals, who 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.

Who We Are

Point32Health is a leading health and wellbeing organization, delivering an ever-better personalized health care experience to everyone in our communities. At Point32Health, we are building on the quality, nonprofit heritage of our founding organizations, Tufts Health Plan and Harvard Pilgrim Health Care, where we leverage our experience and expertise to help people find their version of healthier living through a broad range of health plans and tools that make navigating health and wellbeing easier.

We enjoy the important work we do every day in service to our members, partners, colleagues and communities.

This job has been posted by Ignyte AI on behalf of Point32Health. Ignyte AI is committed to the fundamental principle of equal opportunity and equal treatment for every prospective and current employee. It is the policy of Ignyte AI not to discriminate based on race, color, national or ethnic origin, ancestry, age, religion, creed, disability, sex and gender, sexual orientation, gender identity and/or expression, military or veteran status, or any other characteristic protected under applicable federal, state or local law.

Req ID: R8020

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