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Behavioral Health Outpatient Utilization Management Reviewer # 26-17647

US Tech Solutions, Inc.

canton, MA

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JOB DETAILS
SKILLS
Analysis Skills, Behavioral Health, Case Management, Communication Skills, Contract Requirements, Corporate Compliance, Corporate Policies, Health Plan, Healthcare, Healthcare Providers, Leadership, Licensed Mental Health Counselor (LMHC), Maintain Compliance, Managed Care, Medical Office Administration, Microsoft Excel, Microsoft Office, Microsoft Word, Multitasking, Nursing, Online Communications, Operations Management, Organizational Skills, Outpatient Care, Patient Care Authorizations, Presentation/Verbal Skills, Problem Solving Skills, Regulations, Regulatory Compliance, Regulatory Requirements, Service Delivery, Team Player, Urgent Care, Utilization Management, Writing Skills
LOCATION
canton, MA
POSTED
Today
Duration: 05 Months

Job Summary: 
  • Under the supervision of the Utilization Management Supervisor, the Behavioral Health (BH) Utilization Management (UM) Clinician is responsible for conducting benefit coverage reviews and utilization management in accordance with regulatory guidelines and Enterprise contract requirements.
  • This role works collaboratively with Behavioral Health leadership, providers, and internal teams to ensure clinically appropriate, cost-effective, and compliant delivery of behavioral health services while supporting organizational goals.
  • The clinician escalates urgent member care and compliance concerns, promotes clinical excellence, and works closely with the UM Supervisor and BH Operations Manager to maintain competency and regulatory compliance.
Key Responsibilities
  • Conduct prior authorization and concurrent utilization reviews for behavioral health services using established clinical criteria and review guidelines.
  • Ensure adherence to regulatory requirements, organizational timelines, productivity standards, and authorization processes.
  • Determine benefit coverage, medical necessity, and out-of-network service eligibility for behavioral health requests.
  • Collaborate with providers, UM Support staff, Medical Directors, and Case Management teams to facilitate appropriate care, safe transitions, and member access to services.
  • Communicate clinical variances, authorization decisions, and recommendations to appropriate stakeholders.
  • Support department initiatives by participating in projects, workflow improvements, required meetings, and training sessions.
  • Maintain professional development through continuous learning and participation in professional activities.
  • Perform additional duties and special assignments as needed.
 
Qualifications/ Education Required:
Certification & Licensure
  • Current unrestricted Massachusetts license in a behavioral health area of practice.
  • BS in Nursing, LICSW, LMHC, or another independently licensed behavioral health profession.
 
Experience Required:
  • Direct clinical practice experience within the candidate's credentialed discipline.
  • Health Plan experience performing Utilization Review activities.
  • Strong knowledge of Utilization Management and Care Management principles.
  • Experience using McKesson InterQual Clinical Screening Criteria.
Preferred:
  • 3+ years of experience in a managed care environment.
Required Skills
  • Strong teamwork and collaboration skills across multiple organizational levels.
  • Results-oriented with the ability to meet productivity and business goals.
  • Critical thinking and analytical problem-solving abilities.
  • Ability to adapt to changing business, regulatory, and operational requirements.
  • Strong written and verbal communication skills.
  • Ability to manage multiple priorities in a fast-paced environment.
  • Commitment to confidentiality and corporate compliance policies.
  • Proficiency with Microsoft Office (Word, Excel) and the ability to quickly learn web-based communication and healthcare technology platforms.

About US Tech Solutions:
US Tech Solutions is a global staff augmentation firm providing a wide range of talent on-demand and total workforce solutions. To know more about US Tech Solutions, please visit www.ustechsolutions.com .

US Tech Solutions is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, colour, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.

AI Statement: By applying, you acknowledge that AI-assisted tools may be used during hiring.

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About the Company

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US Tech Solutions, Inc.