RN Utilization Management Reviewer

Blue Cross Blue Shield of Massachusetts•Hingham, MA

1d•$39 - $48

About The Position

The Clinical Utilization Reviewer facilitates care for members who may have complex healthcare needs and authorizes medically necessary services at the appropriate level of care to promote optimal health. The position works independently and collaboratively, applying clinical skills, managed care principles, nationally recognized medical necessity criteria, and company medical policies to support efficient, medically appropriate use of members’ benefits and quality care. The reviewer is part of a dedicated team of professionals, including medical and behavioral health care managers, dieticians, pharmacists, clinicians, and medical directors, who collaborate to facilitate care.

Requirements

Three to five years of relevant experience in a variety of appropriate clinical healthcare settings, such as inpatient, outpatient, or differing levels of care.
Active Massachusetts RN licensure appropriate to the position; restrictions against a license must be disclosed and reviewed.
Self-directed, independent, adaptable, flexible to change, and able to collaborate as a team member.
Ability to assess, analyze, draw conclusions, and construct effective solutions.
Proficiency with multiple IT systems.
Awareness, attitude, knowledge, and skills needed to work effectively with a culturally and demographically diverse population.
High school degree or equivalent, unless otherwise noted.

Nice To Haves

Utilization Management experience.
Licensure in additional states.
For registered nurses, a Bachelor’s degree in nursing (BSN).

Responsibilities

Conduct pre-certification, concurrent, and retrospective reviews, emphasizing utilization management, discharge planning, care coordination, clinical outcomes, and quality of service.
Evaluate members’ clinical status, benefits, and suitability for programs and sites of service to develop a cost-effective, medically necessary plan of care.
Pass the annual InterQual Interrater Reliability Test.
Interact with treatment providers, PCPs, physicians, therapists, and facilities as needed to gather clinical information supporting the plan of care.
Monitor clinical quality concerns, make appropriate referrals, and identify and escalate quality-of-care issues.
Understand member insurance products and benefits, as well as regulatory and NCQA requirements.