RN Utilization Management Reviewer

Blue Cross Blue Shield of Massachusetts•Hingham, MA

3d•$39 - $48•Remote

About The Position

Ready to help us transform healthcare? Bring your true colors to blue. The Role The RN Utilization Management 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. The Team The RN Utilization Management Reviewer is part of a highly dedicated and motivated team of professionals, including medical and behavioral health care managers, dietitians, pharmacists, clinicians, medical directors and more, who collaborate to facilitate care.

Requirements

3-5 years of relevant experience in a variety of appropriate clinical health care settings (inpatient, outpatient, or differing levels of care)
Active licensure in Massachusetts is required, appropriate to position (RN)
Note: Any restrictions against a license must be disclosed and reviewed
Registered nurses only, bachelor’s degree in nursing (BSN) preferred
High school degree or equivalent required unless otherwise noted above

Nice To Haves

Utilization management experience, preferred
Licensure in additional states a plus

Responsibilities

Conduct pre-certification, concurrent, and retrospective reviews with emphasis on utilization management, discharge planning, care coordination, clinical outcomes, and quality of service
Self-directed, independent, adaptive, flexible to change, and able to collaborate as a member of a team
Ability to assess, analyze, draw conclusions, and construct effective solutions.
Proficient with multiple IT systems
Demonstration of awareness, attitude, knowledge, and skills needed to work effectively with a culturally and demographically diverse population