Physician Reviewer

Blue Cross Blue Shield of Massachusetts•Hingham, MA

6d•$230,850 - $282,150

About The Position

The Physician Reviewer evaluates pre- and post-service clinical service requests made by BCBSMA members and providers. The reviewer applies clinical judgment alongside BCBSMA criteria to adjudicate requests and conducts peer-to-peer outreach with treating providers when appropriate. At the request of the Medical Director of the Physician Review Unit (PRU), the reviewer may also provide clinical leadership to other areas of BCBSMA. The role is part of the Physician Review Unit within Health and Medical Management (HMM). The Physician Reviewer reports to the Medical Director and works with actively practicing, board-certified physicians from a variety of specialties, while collaborating with and providing clinical support across the company.

Requirements

MD or DO degree.
Active specialty board certification.
Current, valid, unrestricted license to practice medicine in Massachusetts.
Active clinical practice, necessary to process appeals.
Experience in utilization management in a managed-care or risk-contract environment, such as committee work, large group practice, or peer review.
Leadership skills, including the ability to motivate and develop staff.
Excellent collaboration, negotiation, and written communication skills.
Ability to manage conflict effectively over the phone while maintaining respectful and professional discourse.
Effective oral communication and active listening skills.
High school degree or equivalent, unless otherwise noted above.

Responsibilities

Analyze available clinical documentation, including peer-to-peer outreach when appropriate, and apply BCBSMA criteria and guidelines to determine whether a requested service is medically necessary.
Document coverage decisions in the BCBSMA utilization management system, clearly outlining the medical decision-making and supporting provider and member letters.
Complete coverage determinations in a timely manner to meet unit productivity guidelines and applicable NCQA, MCRA, FEP, Medicare, regulatory, and accreditation standards.
Work as part of the PRU team by sharing ideas, communicating best practices, identifying opportunities to improve unit effectiveness, and contributing to a positive work environment.
Actively participate in unit quality-improvement activities.
Provide clinical leadership to other areas of BCBSMA when requested by the Medical Director of the PRU.