Behavioral Health Utilization Manager – Outpatient Services in Boston, Massachusetts - #71952 | VanderHouwen

Description

Job Id: 71952

Behavioral Health Utilization Manager – Outpatient Services
Our client is seeking a Behavioral Health Utilization Manager – Outpatient Services to support the delivery of high-quality mental health and substance use disorder care across outpatient and non-24-hour diversionary settings. This role serves as a key clinical resource, responsible for evaluating service requests, guiding care decisions, and ensuring services are appropriate, timely, and aligned with established clinical standards. The ideal candidate brings strong clinical judgment, a proactive mindset, and the ability to navigate complex cases in a fast-paced, collaborative environment.

This role is primarily remote with periodic travel to Boston, Massachusetts.

Behavioral Health Utilization Manager – Outpatient Services Responsibilities

• Evaluate outpatient and diversionary behavioral health service requests using sound clinical judgment to determine medical necessity and appropriateness of care.
• Manage a caseload of complex cases, ensuring services align with best practices, regulatory standards, and individual member needs.
• Collaborate with medical leadership on higher-acuity or nuanced cases requiring additional clinical review.
• Identify opportunities for enhanced care coordination and initiate referrals to appropriate internal programs or services.
• Maintain clear, accurate, and timely documentation to support clinical decisions and meet compliance requirements.
• Communicate effectively with providers, internal teams, and external stakeholders to resolve inquiries and support continuity of care.
• Participate in interdisciplinary discussions, case reviews, and clinical meetings to support integrated care planning.
• Monitor utilization patterns and flag potential concerns related to fraud, waste, or abuse, escalating as appropriate.
• Support ongoing process improvement efforts in partnership with leadership to enhance quality and operational efficiency.
• Provide clinical support in urgent or crisis situations, using de-escalation and sound judgment to stabilize member needs.
• Represent the organization in interactions with external partners, including providers and regulatory entities.
• Contribute to special projects and initiatives, offering subject matter expertise as needed.
• May participate in network-related activities or provider collaboration efforts, depending on business needs.

Behavioral Health Utilization Manager – Outpatient Services Qualifications

• Master’s degree in Social Work, Psychology, Counseling, or a related behavioral health discipline.
• 5+ years of experience in a managed care or health plan environment with a focus on behavioral health services.
• Demonstrated experience with utilization management, including medical necessity reviews and clinical decision-making.
• Active, unrestricted independent licensure (e.g., LICSW, LMHC, or LMFT) in a relevant state.
• Strong understanding of outpatient behavioral health services, including mental health and/or substance use treatment.
• Knowledge of regulatory and compliance standards within a managed care setting.
• Experience supporting child and adolescent populations or substance use services is preferred.
• Excellent communication skills, with the ability to engage effectively across multidisciplinary teams and external partners.
• Strong organizational and time management skills, with the ability to manage competing priorities and meet deadlines.
• Analytical mindset with attention to detail and the ability to make sound, data-informed decisions.
• Proficiency with standard business applications and clinical documentation systems.
• Ability to work independently in a remote or fast-paced environment while maintaining high-quality output.

Compensation: (DOE)

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As an eligible contract employee with VanderHouwen, you’ll have access to a full suite of benefits designed with your well-being in mind. Our comprehensive package includes medical, dental, vision, life insurance, short- and long-term disability, and a matching 401(k) to help secure your future.

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