Behavioral Health Utilization Manager (Outpatient and Non-24 Hour Diversionary Services)

It’s an exciting time to join the WellSense Health Plan, a growing regional health insurance company with a 25-year history of providing health insurance that works for our members, no matter their circumstances.

Job Summary:

The Behavioral Health Utilization Manager plays a critical role in ensuring the appropriate and effective delivery of mental health and substance use disorder services. This role serves as a key clinical decision-maker, exercising independent judgment and critical thinking in the evaluation of behavioral health service requests. This position is responsible for managing complex outpatient and non-24-hour diversionary cases, applying clinical expertise to ensure appropriate, timely, and effective care. The role requires a proactive and analytical approach to service delivery, with a focus on clinical quality and compliance.

Our Investment in You:

·       Full-time remote work

·       Competitive salaries

·       Excellent benefits

Key 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.

Potential Additional Responsibilities

·       Providing Network Management in collaboration with other MCEs within Massachusetts for CBHI Providers (may require some travel within Massachusetts)

Qualifications:

Educational Requirements:

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

Experience:

·       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.

Preferred Qualifications:

·       Experience working with Child and Adolescent Behavioral Health Services and/or Substance Use Disorder Services.

·       Familiarity with managed care principles and regulatory compliance requirements.

Licensure and Certification:

·       Active, unrestricted independent licensure in MA and/or NH in one of the following: LICSW, LMHC, or LMFT or RN

·       For ABA UM Position Only: Must hold an active Board Certified Behavior Analyst (BCBA) credential. Additional independent licensure (LICSW, LMHC, LMFT) is preferred.

Core Competencies:

·       Exceptional verbal and written communication skills, with the ability to collaborate effectively across all organizational levels and with external partners.

·       Strong organizational and time management abilities, with a focus on meeting deadlines and managing competing priorities.

·       Capacity to thrive in a fast-paced environment, balancing multiple responsibilities while maintaining accuracy and efficiency.

·       Proficiency in Microsoft Office applications, particularly Outlook, Word, and Excel, along with experience in data management systems.

·       Superior analytical and problem-solving skills with a keen attention to detail.

Work Environment and Physical Demands:

·       Primarily remote role with periodic travel to the Charlestown, MA office for team meetings and training sessions.

·       Additional travel within Massachusetts may be required for individuals with CBHI Network Management expectations.

·       Dynamic and fast-paced work setting requiring adaptability and resilience.

·       Minimal physical exertion required; standard office tasks such as typing and phone use.

·       Consistent and reliable attendance is an essential job requirement.

Compensation Range:

$69,500 – $100,500

This range offers an estimate based on the minimum job qualifications.  However, our approach to determining base pay is comprehensive, and a broad range of factors is considered when making an offer.  This includes education, experience, skills, and certifications/licensure as they directly relate to position requirements; as well as business/organizational needs, internal equity, and market-competitiveness. In addition, WellSense offers generous total compensation that includes, but is not limited to, benefits (medical, dental, vision, pharmacy), merit increases, Flexible Spending Accounts, 403(b) savings matches, paid time off, career advancement opportunities, and resources to support employee and family wellbeing.  

Note: This range is based on Boston-area data, and is subject to modification based on geographic location. 

About WellSense

WellSense Health Plan is a nonprofit health insurance company serving more than 740,000 members across Massachusetts and New Hampshire through Medicare, Individual and Family, and Medicaid plans. Founded in 1997, WellSense provides high-quality health plans and services that work for our members, no matter their circumstances. WellSense is committed to the diversity and inclusion of staff and their members.

Qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, disability or protected veteran status. WellSense participates in the E-Verify program to electronically verify the employment eligibility of newly hired employees.

• Proficiency in applying evidence-based clinical criteria such as InterQual, MCG, or LOCUS/CALOCUS for utilization review decisions
• Strong knowledge of outpatient behavioral health services including individual therapy, group therapy, psychiatric evaluations, and medication management
• In-depth understanding of non-24-hour diversionary services including Partial Hospitalization Programs (PHP) and Intensive Outpatient Programs (IOP)
• Excellent clinical assessment and critical thinking skills to evaluate medical necessity and appropriateness of care
• Strong written and verbal communication skills for documentation, peer-to-peer consultations, and provider relations
• Ability to interpret and apply state and federal behavioral health regulations including mental health parity laws
• Familiarity with NCQA accreditation standards and managed care utilization management requirements
• Proficiency in electronic health record (EHR) systems and utilization management software platforms
• Ability to analyze utilization data and generate reports to identify trends and support quality improvement initiatives
• Strong organizational and time management skills to manage high-volume caseloads and meet regulatory turnaround times
• Collaborative interpersonal skills to work effectively within a multidisciplinary team environment
• Knowledge of recovery-oriented care principles and trauma-informed approaches to behavioral health treatment
• Ability to navigate complex appeals and grievance processes with clinical accuracy and regulatory compliance
• Competency in Microsoft Office Suite including Word, Excel, and Outlook
• Understanding of substance use disorder treatment modalities and co-occurring disorder management

• Minimum of 3 to 5 years of direct clinical experience in behavioral health settings including outpatient mental health or substance use disorder treatment
• At least 2 years of experience in behavioral health utilization management, care management, or managed care within a health plan or managed behavioral health organization
• Experience conducting utilization reviews for outpatient behavioral health and non-24-hour diversionary services
• Demonstrated experience applying clinical criteria such as InterQual, MCG, or LOCUS/CALOCUS in authorization decision-making
• Experience working with Medicaid, Medicare, or commercial insurance populations in a managed care environment
• Prior experience collaborating with multidisciplinary clinical teams including psychiatrists, social workers, and care coordinators
• Experience with NCQA accreditation processes and compliance with utilization management standards
• Background in conducting peer-to-peer consultations with treating providers and external clinicians
• Experience supporting appeals, grievances, and adverse determination processes in a clinical capacity
• Familiarity with Massachusetts behavioral health regulations and mental health parity compliance is strongly preferred
• Active and unrestricted licensure as a Licensed Independent Clinical Social Worker (LICSW), Licensed Mental Health Counselor (LMHC), Licensed Professional Counselor (LPC), Registered Nurse (RN), or equivalent clinical license in the state of Massachusetts
• Master's degree or higher in social work, counseling, psychology, nursing, or a related behavioral health field is required
• Experience with quality improvement projects and utilization trend analysis in a managed care or health plan setting
• Prior experience using utilization management platforms and electronic health record systems in a clinical or administrative capacity