Behavioral Health Specialist

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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.

Job Summary:

The Behavioral Health Specialist is responsible for managing incoming prior authorization and inpatient admission requests for behavioral health services. This role involves reviewing submissions, gathering clinical documentation from providers, verifying member eligibility, and entering information into the Jiva system. The specialist ensures requests are routed appropriately to the clinical team, communicates determinations, resolves escalated issues, and collaborates closely with behavioral health clinicians to support timely and accurate decision-making.

Our Investment in You:

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

 Key Functions/Responsibilities:

• Manages and prioritizes incoming behavioral health authorization and inpatient admission requests; processes designated services in accordance with departmental protocols and routes cases appropriately to the behavioral health clinical team.
• Verifies member eligibility and enters all required data into the Jiva system with accuracy and efficiency to ensure compliance with turnaround time standards.
• Communicates with healthcare providers to request, clarify, or follow up on clinical information necessary for authorization determinations.
• Oversees incoming requests received through Jiva, fax, and email, ensuring accurate data entry and consistent adherence to established workflows and quality standards.
• Consistently meets or exceeds productivity benchmarks while maintaining compliance with regulatory and internal turnaround time requirements.
• Notifies providers of authorization decisions, addresses escalated provider inquiries, and ensures clear, professional, and timely communication at all times.
• Collaborates with internal departments to enhance understanding of the authorization process and maintains up-to-date knowledge of departmental policies, procedures, and system functionalities.
• Actively participates in team functions, including case triage, shared inbox and voicemail management, and department meetings.

Supervision Exercised:

• None

Supervision Received:

• Direct supervision weekly

Qualifications:

Education Required:

• Associate’s Degree in Healthcare, Nursing, Social Work or related area, or the equivalent combination of training and experience is required.

Education Preferred:

•  Knowledge of medical terminology.

Experience Required:

• A minimum of 2 years of experience in a high-volume healthcare office, hospital administration, data entry office, or customer service call center. 

Experience Preferred/Desirable:

•  Familiarity with Jiva, FACETS, or other healthcare databases.
•  Experience working in health plan utilization or claims processing.
•  Previous customer service experience is desirable.
• Behavioral Health experience.

Required Licensure, Certification or Conditions of Employment: 

• Pre-employment background check

Competencies, Skills, and Attributes:

•       Proven ability to prioritize and manage multiple tasks in a fast-paced environment while meeting deadlines.
•      Capacity to process high volumes of requests accurately.
•       Excellent listening, verbal, and written communication skills and a strong customer service focus
•      Teamwork and collaboration skills.
•      Proficiency in Microsoft Office products.

Working Conditions and Physical Effort:

•  Regular and reliable attendance is an essential function of the position.
• Position is fully remote, with no or very limited physical effort needed and minimal exposure to physical hazards.
• Flexibility to work overtime during peak periods.

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.

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.

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