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.

Our Investment in You:

• Full-time remote work
• Competitive salaries
• Excellent benefits

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.

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.

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 Massachusetts and/or New Hampshire in one of the following: LICSW, LMHC, LMFT, or RN licensure.

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.

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. 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