Utilization Review Clinician

The Utilization Review Clinician is responsible for conducting ongoing clinical reviews to include monitoring and assessing levels of care criteria and communicating findings to managed care organizations. The Utilization Review Clinician is responsible for educating treatment teams regarding level of care criteria, authorizations and community support options.

About Us

Bournewood Health Systems is a behavioral health organization with a main campus in Brookline, MA and satellite sites in Woburn, Lowell, and Dedham. We provide acute psychiatric inpatient services and partial hospital/outpatient psychiatric programs. We are dedicated to providing quality, evidence-based and person-centered treatment for people with mental health and substance use conditions in a safe and respectful environment in partnership with the individuals and families we serve, focusing on support, hope and recovery. 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. We stand firmly for providing a safe and therapeutic environment for patients, families and staff. All Bournewood employees are continuously trained in this philosophy. All candidates must be able and willing to promote the values of trauma-informed and patient-centered care.

Qualifications:

Candidate must at least have a Bachelor degree; Master Level Clinician is preferred; must have at least six (6) years of experience in a behavioral health care setting and at least 2 years previous experience

Essential Functions:

• Monitors and assesses current level of care for assigned cases and recommends changes to the clinical team and/or UM Director; Demonstrates the skills required to organize relevant information and accurately reiterate requirements to MCOs and Treatment Team members
• Conducts clinical reviews with designated insurers and conducts reviews on the appropriate day and at the designated time; Effectively coordinates collection of all pertinent clinical data to support HLOC Reports obtained authorization to team members and, should request for authorization be denied, alerts the UM Director and/or administration and attending MD
• 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
  
  Essential Competencies:

• Ability to assess the clinical status of patients as it relates to HLOC issues; responds to all treatment team members and prospective clients and family members in a compassionate and respectful manner; maintains a calm and respectful demeanor while handling difficult people or situations
• Knowledge of mental health conditions and behaviors necessitating certain levels of care for all age levels; working knowledge of current state agencies, both regarding their functions and criteria for continued eligibility
• Knowledge of substance use conditions and dual diagnosis treatment and level of care criteria for all age levels
• Exhibit sensitivity to clients and families with the knowledge that people are under considerable stress
• Always respond to persons served with kindness, respect and compassion
• Ability to prioritize daily tasks and follows through on assignments. Strong communication skills, both verbal and written. Develops and maintains effective working relationships with Admissions staff.
• Ability to use current SDK system and a working knowledge of Bournewood Health System’s email system to coordinate the flow of essential information with other Bournewood employees (ie. Admissions, billing, etc.)
• Ability to assess the clinical status of patients and recognize/assess a range of trauma-related behaviors