Utilization Management Reviewer - Behavioral Health

Blue Cross Blue Shield of Massachusetts•Hingham, MA

2d•$39 - $47•Onsite

About The Position

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. 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.

Requirements

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
Behavioral Health professional with an active Massachusetts license: Registered Nurse, LICSW, LMHC, BCBA
3-5 years of clinical experience in Behavioral Health Care settings

Nice To Haves

Utilization Management experience preferred
CCM or other applicable certification(s) desirable

Responsibilities

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