Behavioral Health Psychologist Reviewer

The Behavioral Health Psychologist Reviewer will primarily perform utilization management and provider payment reviews for all Point32Health products, as well as any partner entities at the direction of Behavioral Health Medical Director Team Leader for Utilization Management (UM) and/or the Medical Director of UM. These functions will include prospective, concurrent, and retrospective utilization reviews including both member facing initial reviews and appeals. They will work closely with colleagues in UM and Medical Management, and with other departments as needed, including but not limited to Claims Operations, Actuarial, and Quality Management. They will assist with performing clinical reviews of provider claims payment disputes, perform retrospective claims audits of medical records, and review potential quality of care issues and credentialing related to their specialties.
Essential functions may occur simultaneously; therefore, the Behavioral Health Psychologist Reviewer must be able to appropriately handle each essential function, prioritize them and seek assistance when necessary. The expectation is for these functions to be performed on a consistent and regular basis, using good judgment. Ability to learn and apply company policies consistently and to seek guidance, when necessary, will be of utmost importance.

• Performs clinical review of prospective, concurrent, and retrospective coverage requests for Neuropsychological and Psychological Testing services requiring prior authorization and medical necessity review for all lines of business.
• Participates in biannual inter-rater reliability exercises.
• Performs clinical review of expedited and standard appeals for all lines of business.
• Communicates with providers, provider groups, facilities, and others as necessary to obtain information and any resolve clinical issues and concerns.
• Provides psychologist expertise and input for provider payment disputes.
• Supports the provider inquiry line for peer-to-peer discussions.

• They are required to have a current unrestricted license as a psychologist in Massachusetts
• Candidate will be a Ph.D. or Psy.D. psychologist.
• Minimum of five years of clinical experience is required.
• Significant utilization management, quality and / or management experience, either at another health plan or at a local provider unit, medical group, or health care facility is preferred.

• Render/provide appeal decisions following legacy Tufts Health Plan or Harvard Pilgrim Health Care claims payment policies.
• Render medical necessity coverage determinations in accordance with legacy Tufts Health Plan or Harvard Pilgrim Health Care Medical Necessity Guidelines and the member’s EOC / benefit document.
• Have an understanding of principles of utilization management and quality assurance.
• Have the skills to communicate with and educate Point32Health peers as well as Tufts Health Plan or Harvard Pilgrim Health Care participating physicians and psychologists and other providers in a collegial manner.
• Be an effective team player, with excellent interpersonal and cross-departmental collaboration skills.
• Performs utilization management activities in accordance with accreditation standards and regulatory guidelines described in legacy Tufts Health Plan or Harvard Pilgrim Health Care UM Policy and Procedure Manual.