Clinical Reviewer

Blue Cross of Idaho•Bozeman, MT

1d•$73,321 - $102,650•Hybrid

About The Position

Blue Cross of Idaho is seeking a Clinical Reviewer to support Healthcare Operations initiatives. This role ensures the delivery of medically necessary, appropriate, cost-effective, and timely quality health care services through a focused procedural review and authorization process. The position has a preference for being based in Meridian, Idaho, and offers a hybrid work location, with potential consideration for fully remote work within a mutually acceptable location.

Requirements

3 years’ relevant experience
Associates Degree in Nursing or Bachelor’s Degree in Social Work; or equivalent work experience (Two years’ relevant work experience is equivalent to one-year college)
Valid unrestricted Idaho Registered Nursing License
Valid unrestricted Idaho Social Worker License
High degree verbal and written communication
Independent and critical thinking
Handle multiple projects simultaneously
Work well in a team environment

Nice To Haves

Responsibilities

Make clinical decisions for Behavioral Health and/or Medical requests using approved and accepted plan policies and criteria.
Determine eligibility and benefit coverage according to member and provider contracts.
Identify appropriate members for medical or behavioral health case management.
Respond to requests for authorization of Behavioral Health and/or Medical services and inpatient procedures.
Document and report potential quality of care or service issues to leadership.
Perform review of business workflows to ensure consistent application.
May provide review according to established criteria for procedural authorization.
Perform other duties and responsibilities as assigned.