Ready to help us transform healthcare? Bring your true colors to blue.
The Role
The Clinical Utilization Reviewer is responsible for facilitating care for members who may have complex healthcare needs, authorizing medically necessary services at the right level of care to promote optimal health.
This position is self-directed and works independently and collaboratively to facilitate care using clinical skills, principles of managed care, nationally recognized medical necessity criteria, and company medical policies to conduct reviews that promote efficient and medically appropriate use of the member’s benefit to provide the best quality care.
This position is eligible for the following personas: eWorker, mobile and resident.
The Team
The Clinical Utilization Reviewer is part of a highly dedicated and motivated team of professionals, including medical and behavioral health care managers, dieticians, pharmacist, clinicians, medical directors and more, who collaborate to facilitate care.
Your Day to Day :
Conduct pre-certification and concurrent and retrospective clinical review of in-state and out-of-state inpatient cases at acute residential treatment programs and partial hospitalization through the application of evidence-based medical necessity criteria and BCBSMA policies and procedures
Focus on efficient utilization management with emphasis on discharge planning
Understand and appropriately manages member’s benefits to maximize health care quality
Collaborate with physician reviewers, case managers, project leaders and associates within BCBSMA to optimize member care and ensure a constructive provider experience
Facilitate review process by communication with members/families, providers, medical staff and/or others to obtain and/or share information relating to benefits and the BCBSMA utilization management process
Collaborate with members/families, providers, medical staff and/or other members of the treatment team to coordinate and support health action plans developed by providers that include treatment goals, interventions, and expected clinical outcomes and that support quality and medical management goals and objectives
Educate and support members/families regarding benefits, eligibility, BCBSMA policies and processes with the goal to empower self-advocacy
Identify and refer members who may benefit from high-risk case management and disease state management intervention
Maintain professional licensure and seeks out continuous learning opportunities to enhance understanding of clinical management, trends in patient care, utilization management and other topics applicable to carrying out job responsibilities in an educated manner
Utilize the computer systems to efficiently enter case information, check benefits and eligibility, look up policy and procedures, validate provider contractual status and other functions relating to the execution of key responsibilities
Exhibit customer satisfaction orientation in every aspect of carrying out responsibilities
Meet or exceed annual performance goal of 90% cumulatively for case audits and recorded call audits, where applicable.
Other responsibilities as assigned by management
This document is not an exhaustive list of all responsibilities, skills, duties, requirements, or working conditions associated with the job. Employees may be required to perform other job-related duties as required by their supervisor, subject to reasonable accommodation.
We’re Looking for :
Solid clinical knowledge in Behavioral Health. Specialty knowledge a plus
Excellent organizational skills, ability to manage multiple ongoing tasks
Strong problem-solving ability under pressure of timeliness turnaround deadlines
Excellent communication skills. Able to discuss sensitive/ confidential information in a professional, unbiased manner
Proven customer service skills
Intermediate ease of use with computers and a working understanding of common computer software such as Microsoft Word, Excel and Outlook
Ability to integrate as part of a working team, and function independently to complete assigned workload
Achieve a passing score on the yearly InterQual, behavioral health medical necessity criteria, interrater reliability test
What You Bring :
Behavioral Health professional with an active Massachusetts license: Registered Nurse, LICSW, LMHC
3-5 years of clinical experience in Behavioral Health Care settings
Utilization Management experience preferred
CCM or other applicable certification(s) desirable
#LI-REMOTE
Minimum Education Requirements:
High school degree or equivalent required unless otherwise noted above
Location Hingham Time Type Full time
Hourly Range: $37.43 – $45.75
The job posting range is the lowest to highest salary we in good faith believe we would pay for this role at the time of this posting. We may ultimately pay more or less than the posted range, and the range may be modified in the future. An employee’s pay position within the salary range will be based on several factors including, but limited to, relevant education, qualifications, certifications, experience, skills, performance, shift, travel requirements, sales or revenue-based metrics, and business or organizational needs and affordability.
This job is also eligible for variable pay.
We offer comprehensive package of benefits including paid time off, medical/dental/vision insurance, 401(k), and a suite of well-being benefits to eligible employees.
Note: No amount of pay is considered to be wages or compensation until such amount is earned, vested, and determinable. The amount and availability of any bonus, commission, or any other form of compensation that are allocable to a particular employee remains in the Company’s sole discretion unless and until paid and may be modified at the Company’s sole discretion, consistent with the law.
WHY Blue Cross Blue Shield of MA?
We understand that the confidence gap and imposter syndrome can prevent amazing candidates coming our way, so please don’t hesitate to apply. We’d love to hear from you. You might be just what we need for this role or possibly another one at Blue Cross Blue Shield of MA. The more voices we have represented and amplified in our business, the more we will all thrive, contribute, and be brilliant. We encourage you to bring us your true colors, , your perspectives, and your experiences. It’s in our differences that we will remain relentless in our pursuit to transform healthcare for ALL.
As an employer, we are committed to investing in your development and providing the necessary resources to enable your success. Learn how we are dedicated to creating an inclusive and rewarding workplace that promotes excellence and provides opportunities for employees to forge their unique career path by visiting our Company Culture page. If this sounds like something you’d like to be a part of, we’d love to hear from you. You can also join our Talent Community to stay “in the know” on all things Blue.
At Blue Cross Blue Shield of Massachusetts, we believe in wellness and that work/life balance is a key part of associate wellbeing. For more information on how we work and support that work/life balance visit our ” How We Work ” Page.