Clinical Utilization Reviewer – Behavioral Health

Blue Cross and Blue Shield of Massachusetts Inc.; Hingham (MA); On-site; USD 53,000 - 65,000; Full time

Benefits offered by this job

Paid time off

Medical/dental/vision insurance

401(k)

Job summary

Blue Cross Blue Shield of Massachusetts, a leading not-for-profit health plan, seeks a Clinical Utilization Reviewer to facilitate care for members with complex needs and to authorize services at the right level of care. The role emphasizes independent work, collaboration with clinicians, and adherence to medical policies to promote efficient, high-quality member care.

Responsibilities include pre-certification, concurrent and retrospective reviews at inpatient programs, discharge planning

Qualifications

• Solid clinical knowledge in Behavioral Health.
• Excellent organizational skills.
• Strong problem-solving ability under pressure of timeliness turnaround deadlines.
• Excellent communication skills; able to discuss sensitive information professionally.
• Proven customer service skills.
• Intermediate ease of use with computers and common software (Word, Excel, Outlook).
• Ability to work as part of a team while completing independent workload.

Responsibilities

• Conduct pre-certification and concurrent and retrospective clinical reviews of inpatient cases using evidence-based criteria and BCBSMA policies.
• Focus on efficient utilization management with emphasis on discharge planning.
• Understand and manage members' benefits to maximize health care quality.
• Collaborate with physicians, case managers and staff to optimize member care.
• Communicate with members, families and providers to obtain/share information about benefits and utilization management.

Job description

Blue Cross Blue Shield of Massachusetts, a leading not-for-profit health plan, seeks a Clinical Utilization Reviewer to facilitate care for members with complex needs and to authorize services at the right level of care. The role emphasizes independent work, collaboration with clinicians, and adherence to medical policies to promote efficient, high-quality member care.

Responsibilities include pre-certification, concurrent and retrospective reviews at inpatient programs, discharge planning