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.

Job Summary:

The UM Director manages the organization of the daily inpatient and outpatient UM teams functions and schedule of reviews with MCO’s, monitors the utilization of levels of care for clients, coordinates clinical reviews with insurers, initiates, tracks, completes, and submits appeals to insurances companies. Conducts QI studies for the Department, schedules and supervises UM inpatient and outpatient staff, provides direct evaluations as indicated, ensuring persons are treated with kindness, respect and compassion to determine level of care. Assist teams with obtaining appropriate resources for disposition planning. This position reports to the Chief Medical Officer.

Primary Responsibilities (include but are not limited to)

• Reviews and monitors utilization for members and plans and implements solutions that directly influence quality of care and financial liability-based on the needs of the member.
• Collaborate with treatment team to discuss clinical authorization and quality of care.
• Interact with providers and facilities in a professional, respectful manner to coordinate treatment and discharge planning.
• Consistent and timely response to emails and other communications relating to utilization review.
• Other duties as assigned.

Responsibilities:

• Manages and leads utilization management of both inpatient and outpatient UM teams.
• Coordinates Department meetings, maintains minutes, conducts QI studies and reports on same (or delegates the reporting to supervisee) to the QI Committee.
• Writes, reviews, completes, and tracks all appeals on any denials of stay/authorization to the insurance companies. Initiates appeals on behalf of treatment team and patient as required.
• Tracks and manages pay for performance program through insurances.
• Provides feedback to executive team of insurance, authorization, and denial trends and changes.
• Monitors and assesses current level of care for clients and recommends changes as necessary to clinical teams.
• Conducts clinical reviews with insurers, reports authorizations and/or denials to administrative and/or clinical staff.
• Provides education regarding UM and Provider Contract UM requirements to clinical teams as necessary.
• Reviews with Chief Medical Officer length of stay and disposition issues.
• Provides ongoing monitoring of volume analysis for internal data collection and for quality assurance monitoring.

Knowledge, Skills & Abilities

Education, Licensure or Certification:

• Master level clinician (i.e. MSN, MSW)
• Independent license preferred (but not required)

Work Experience or Related Experience:

• At least 3 years of experience of supervisory/management experience.
• At least 5 years of experience with working with insurance utilization.
• At least 5 years of clinical experience working with dual diagnoses, mental health, adult, and adolescent populations preferred.
• Experience in a behavioral health environment is strongly preferred.

Specialized Knowledge, Skills & Abilities:

• The ability to be proactive and self-directed utilizing good time management, decision-making, and organization skills is required. Individuals must be able to prioritize multiple tasks
• Must have the ability to work in a fast-paced expanding environment