Clinical Utilization Reviewer: Drive Care & Outcomes

Blue Cross and Blue Shield of Massachusetts Inc.; Hingham (MA); On-site; USD 58,000 - 71,000; Full time

Benefits offered by this job

Paid time off

Medical/dental/vision insurance

401(k)

Well-being benefits

Job summary

Blue Cross Blue Shield of Massachusetts is seeking a Clinical Utilization Reviewer to support members with complex care needs. The role involves authorizing medically necessary services and coordinating care using clinical judgment and policy guidelines.

Ideal candidates will have MA licensure (PT), 3–5 years in clinical health settings, and experience with utilization management. This is a full-time, on-site role in Massachusetts with a comprehensive benefits package.

Qualifications

• 3–5 years of experience in clinical health care settings (inpatient, outpatient, or varying levels of care).
• Utilization Management experience preferred.
• Active licensure in Massachusetts is required for this position (PT).
• Licensure in additional states is a plus.
• Note: Any license restrictions must be disclosed and reviewed.

Responsibilities

• Conduct pre-certification, concurrent, and retrospective reviews with emphasis on utilization management, discharge planning, care coordination, 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 to gather clinical information supporting the plan of care.
• Monitor clinical quality concerns and elevate issues as needed.

Skills

Self-directed

Independent

Flexible to change

Team collaboration

Assess and analyze

IT systems proficiency

Cultural competence

Education

Massachusetts PT license

High school diploma

Multi-state licensure

Job description

Blue Cross Blue Shield of Massachusetts is seeking a Clinical Utilization Reviewer to support members with complex care needs. The role involves authorizing medically necessary services and coordinating care using clinical judgment and policy guidelines.

Ideal candidates will have MA licensure (PT), 3–5 years in clinical health settings, and experience with utilization management. This is a full-time, on-site role in Massachusetts with a comprehensive benefits package.