Blue Cross and Blue Shield Association - Hingham, MA
posted 24 days ago
About the position
The Clinical Utilization Reviewer is responsible for facilitating care for our Medicare Advantage 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. This role is eligible for our eWorker, Mobile, and Resident personas. This position can be fully remote, with a 1x/month staff meeting in our Hingham, MA office. Hours of work: 8:30a - 4:30p EST.
Responsibilities
- Conduct pre-certification, concurrent, and retrospective reviews with emphasis on utilization management, discharge planning, care coordination, clinical outcomes, and quality of service.
- Evaluate members' clinical status, benefits, and appropriateness for programs and sites of service to develop a cost-effective, medically necessary plan of care.
- Pass annual InterQual Interrater Reliability Test.
- Interact with treatment providers, PCPs, physicians, therapists, and facilities as needed to gather clinical information to support the plan of care.
- Monitor clinical quality concerns, make referrals appropriately, identify and escalate quality of care issues.
- Understand member insurance products and benefits, as well as regulatory and NCQA requirements.
Requirements
- 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.
- 3-5 years 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.
Nice-to-haves
- Utilization Management experience, preferred.
- Experience with Medicare Advantage, preferred.
- Licensure in additional states a plus.
- For Registered Nurses Only: A Bachelor's degree in nursing (BSN) is preferred.
Benefits
- Paid time off
- Medical/dental/vision insurance
- 401(k)
- Suite of well-being benefits
