Clinical Utilization Specialist

5 days ago


Brookline, Massachusetts, United States Alita Care, LLC Full time

About Us

Bournewood Health Systems is a behavioral health organization dedicated to providing quality, evidence-based and person-centered treatment for people with mental health and substance use conditions. We are committed to a philosophy and an environment of care in which we treat people with dignity, respect and mutuality; protect their rights; provide the best care possible; support them in returning to their natural communities; and include patients and families as partners in their treatment.

Job Summary

The Utilization Review Clinician conducts ongoing clinical reviews with various insurers to obtain clinical authorization for the appropriate levels of care. This role requires a Master level clinician with experience in behavioral health, preferably with utilization review process and insurances. The ideal candidate will have strong communication skills and be able to effectively coordinate collection of all pertinent clinical data to support HLOC.

Key Responsibilities

  • Monitors and assesses current level of care for assigned cases and recommends changes to the clinical team and/or UM Director.
  • Conducts clinical reviews with designated insurers and coordinates collection of all pertinent clinical data to support HLOC.
  • Initiates appeals as requested and completes data collection as requested for QI indicators.
  • Covers Utilization Management Director's time away as necessary.
  • Completes daily discharge forms to respective Insurers.

Requirements

  • Master level clinician (MSN, MSW, MA etc.) preferred.
  • 5 years of experience in behavioral health preferred.
  • Experience with utilization review process, and insurances preferred.


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