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

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. 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

The Behavioral Health Utilization Manager for Inpatient and 24-Hour Diversionary Services is responsible for overseeing the appropriate and effective utilization of mental health and substance use disorder services across inpatient and residential care settings. This role entails conducting concurrent reviews, facilitating discharge planning, ensuring smooth transitions of care, and collaborating with care managers and state agencies to support members in achieving optimal health outcomes. Our Investment in You: Full-time remote work Competitive salaries Excellent benefits

Use advanced clinical judgment and critical thinking to evaluate inpatient and 24-hour behavioral health services, determining the appropriateness of care based on individual member needs, clinical presentations, and professional standards. Coordinating comprehensive discharge plans in collaboration with care managers, providers, and state agencies to ensure timely access to community-based support. Identify potential risks and barriers to recovery during transitions of care and proactively implement creative solutions to support continuity and member stabilization. Develop and oversee individualized care plans in partnership with hospital treatment teams, ensuring alignment with clinical objectives and long-term recovery goals. Evaluate and approve requested behavioral health services by integrating clinical expertise with benefit considerations, provider resources, and member-specific factors. Monitor inpatient stays to ensure that clinical decision-making aligns with organizational values, contractual expectations, and overall quality of care goals. Proactively identify members who would benefit from enhanced care coordination and initiate referrals to high-touch case management and wraparound services. Maintain timely and accurate documentation of clinical assessments, interventions, and decisions, reflecting professional discretion and adherence to ethical and regulatory standards. 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, to address systemic barriers and contractional expectations. Assess cases for potential indicators of Fraud, Waste, or Abuse and report findings per organizational protocols. Provide crisis intervention support using clinical judgment to de-escalate situations and assist members in stabilizing their conditions. Collaborate with Medical Directors and clinical leadership on strategic initiatives aimed at improving access, reducing unnecessary hospitalizations, and enhancing member outcomes. 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 Potential Additional Responsibilities: Management of members who are Boarding in Emergency Departments. Including assessing for possible diversion to lower levels of care or providing placement advocacy