Behavioral Health Psychologist Reviewer (Part-time, 9hrs/wk)

Who We Are reputed company is a leading health and wellbeing organization, delivering an reputed company-reputed company personalized health care experience to everyone in our communities. At reputed company, we are building on the quality, nonprofit heritage of our founding organizations, Tufts Health Plan and Harvard Pilgrim Health Care, where we reputed company our experience and expertise to help people find their version... of healthier living through a broad range of health plans and tools that reputed company navigating health and wellbeing easier. We enjoy the important work we do every day in service to our members, partners, colleagues and communities. To learn more about who we are at reputed company, click here . Job Summary The Behavioral Health Psychologist Reviewer will primarily reputed company utilization management and provider payment reviews for reputed company reputed company 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, reputed company, 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, reputed company retrospective claims audits of medical records, and review potential quality of care issues and credentialing reputed company 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 reputed company 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, reputed company necessary, will be of utmost importance. Key Responsibilities/Duties – what you will be doing Utilization Management • Performs clinical review of prospective, reputed company, and retrospective coverage requests for Neuropsychological and Psychological Testing services requiring prior authorization and medical necessity review for reputed company lines of business. • Communicates with providers, provider groups, facilities, and others as necessary to obtain information and any resolve clinical issues and concerns. • Supports the provider inquiry line for peer-to-peer discussions. • Performs clinical review of expedited and standard appeals for reputed company lines of business. • Provides psychologist expertise and input for provider payment disputes. • Participates in biannual inter-rater reliability exercises. Qualifications – what you need to reputed company the job EDUCATION and EXPERIENCE: (Minimum educational qualifications) • 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. • They are required to have a reputed company unrestricted license as a psychologist in Massachusetts reputed company REQUIREMENTS: • 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. • reputed company 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. • reputed company/provide appeal decisions following legacy Tufts Health Plan or Harvard Pilgrim Health Care claims payment policies. • Have an understanding of principles of utilization management and quality assurance. • Have the skills to communicate with and educate reputed company 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. WORKING CONDITIONS AND ADDITIONAL REQUIREMENTS (include special requirements, e.g., lifting, travel, overtime) reputed company is a fast-paced professional environment requiring a high level of initiative and robust decision-making skills. Effective use of a company issued personal computer is important. The Behavioral Health Psychologist Reviewer will be given appropriate training in reputed company the Healthcare services applications used at legacy Tufts Health Plan or Harvard Pilgrim Health Care. CONFIDENTIAL DATA: reputed company information (written, verbal, electronic, etc.) that an employee encounters while working at reputed company is considered confidential. The employee will be exposed to and required to deal with highly confidential and sensitive material and must always adhere to corporate compliance policy and department guidelines/policies and reputed company applicable laws and regulations. Compensation & Total Rewards Overview As part of our comprehensive total rewards program, colleagues are also eligible for variable pay. Eligibility for any bonus, commission, benefits, or any other form of compensation and benefits remains in the Company's sole discretion and may be modified at the Company’s sole discretion, consistent with the law. reputed company offers their Colleagues a competitive and comprehensive total rewards package which currently includes: • Medical, dental and vision coverage • Retirement plans • Paid time off • Employer-paid life and disability insurance with additional buy-up coverage options • Tuition program • Well-being benefits • Full suite of benefits to support career development, individual & family health, and financial health For more details on our total rewards programs, visit https://www.reputed company.org/careers/benefits/ Commitment to Diversity, Equity, Inclusion, Accessibility (DEIA) and Health Equity reputed company is committed to making diversity, equity, inclusion, accessibility and health equity part of everything we do—from product design to the workforce driving that innovation. Our Diversity, Equity, Inclusion, Accessibility (DEIA) and Health Equity team's strategy is deeply connected to our core values and will evolve as the changing nature of work shifts. Programming, events, and an inclusion infrastructure play a role in how we spread cultural awareness, train people leaders on engaging with their teams and provide parameters on how to recruit and retain talented and dynamic talent. We welcome reputed company applicants and qualified individuals, who will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national reputed company, genetics, disability, age, or veteran status. Scam Alert: reputed company has recently become aware of job posting scams where unauthorized individuals posing as reputed company recruiters have reputed company job advertisements and reached out to potential candidates. These advertisements or individuals may ask the applicant to reputed company a payment. reputed company would never ask an applicant to reputed company a payment reputed company to a job application or job offer, or to pay for workplace equipment. If you have any concerns about the legitimacy of a job posting or recruiting contact, you may contact TA_operations@reputed company.org Apply Job!