Behavioral Health Utilization Specialist

Blue Cross Blue Shield of Massachusetts; Hingham (MA); On-site; USD 111,434,000 - 135,924,000; Full time

Benefits offered by this job

Paid time off

Medical/dental/vision insurance

401(k)

Job summary

Blue Cross Blue Shield of Massachusetts in Massachusetts is seeking a Clinical Utilization Reviewer to facilitate care for members with complex needs. You will authorize medically necessary services at the appropriate level of care, leveraging clinical skills and BCBSMA policies to promote quality outcomes.

You will collaborate with medical directors, care managers and providers, perform pre-cert, concurrent and retrospective reviews, and educate members about benefits.

Qualifications

• Behavioral Health clinical knowledge required.
• Active Massachusetts license as RN/LICSW/LMHC/BCBA is required.
• Utilization Management experience preferred.
• CCM or related certification desirable.

Responsibilities

• Conduct pre-certification, concurrent and retrospective reviews for in-state and out-of-state inpatient cases.
• Emphasize discharge planning and efficient utilization management.
• Understand and manage member benefits to maximize health care quality.
• Collaborate with physicians, case managers and project teams to optimize member care.
• Educate members about benefits and BCBSMA policies to empower self-advocacy.
• Maintain licensure and pursue ongoing learning in clinical management and utilization review.

Skills

Behavioral Health

Organizational skills

Problem solving

Communication skills

Customer service

MS Office

Team player

InterQual

Education

Massachusetts license (RN/LICSW/LMHC/BCBA)

CCM or related certification desirable

Tools

Microsoft Word

Excel

Outlook

Job description

Blue Cross Blue Shield of Massachusetts in Massachusetts is seeking a Clinical Utilization Reviewer to facilitate care for members with complex needs. You will authorize medically necessary services at the appropriate level of care, leveraging clinical skills and BCBSMA policies to promote quality outcomes.

You will collaborate with medical directors, care managers and providers, perform pre-cert, concurrent and retrospective reviews, and educate members about benefits.