Behavioral Health Utilization Reviewer

Blue Cross and Blue Shield of Massachusetts, Inc.; Hingham (MA); On-site; USD 81,000 - 99,000; Full time

Job summary

Blue Cross Blue Shield of Massachusetts, Inc. is seeking a Clinical Utilization Reviewer to support members with complex health needs by authorizing appropriate services and promoting high-quality care.

The role blends independent work with team collaboration to apply medical necessity criteria and internal policies. The reviewer will conduct pre-certification, concurrent, and retrospective reviews across inpatient and partial hospitalization settings, emphasizing discharge planning and

Qualifications

• Behavioral Health expertise with active MA license.
• 3–5 years of clinical experience in Behavioral Health Care settings.
• Utilization Management experience preferred.
• CCM or similar certification desirable.

Responsibilities

• Perform pre-certification, concurrent, and retrospective reviews using evidence-based criteria and BCBSMA policies.
• Emphasize discharge planning and efficient utilization management.
• Understand member benefits to maximize care quality and access.
• Collaborate with physicians, case managers, and care teams to optimize member care.
• Communicate with members, providers, and staff to share information on benefits and processes.
• Support health action plans and treatment goals with providers.

Skills

Behavioral Health

Organizational skills

Problem solving

Communication skills

Customer service

MS Office

Teamwork

InterQual criteria

Education

License: MA MA licensed professional (RN/LICSW/LMHC/BCBA)

CCM certification desirable

Tools

Microsoft Word

Excel

Outlook

Job description

Blue Cross Blue Shield of Massachusetts, Inc. is seeking a Clinical Utilization Reviewer to support members with complex health needs by authorizing appropriate services and promoting high-quality care.

The role blends independent work with team collaboration to apply medical necessity criteria and internal policies. The reviewer will conduct pre-certification, concurrent, and retrospective reviews across inpatient and partial hospitalization settings, emphasizing discharge planning and