Physician Reviewer

Blue Cross and Blue Shield of Massachusetts Inc.; Hingham (MA); On-site; USD 231,000 - 282,000; Full time

Job summary

The physician reviewer at Blue Cross Blue Shield of Massachusetts in Hingham evaluates pre and post-service clinical requests for members and providers, using BCBSMA criteria and clinical judgment to adjudicate coverage decisions. This role requires peer-to-peer collaboration with treating providers and leadership from the PRU.

You will join a team of board-certified physicians across specialties, providing clinical support, leadership, and adherence to NCQA and Medicare standards, while

Qualifications

• MD or DO degree with an active specialty board certification.
• Current, valid, unrestricted license to practice medicine in the state of Massachusetts.
• Active clinical practice necessary to process appeals.
• Experience in Utilization Management in a managed-care or risk contract environment.

Responsibilities

• Analyze available clinical documentation and apply BCBSMA criteria to determine medical necessity for coverage.
• Document coverage decisions in the utilization management system with clear medical rationale.
• Complete coverage determinations in a timely fashion meeting NCQA, MCRA, FEP, Medicare standards.
• Collaborate with the PRU team, share best practices and contribute to unit effectiveness.
• Participate in all unit quality improvement activities.

Skills

Leadership

Collaboration & negotiation

Written communication

Oral communication & listening

Education

MD or DO with board certification

MA medical license

Active clinical practice for appeals

Utilization Management experience

High school degree or equivalent

Job description

Ready to help us transform healthcare? Bring your true colors to blue. The physician reviewer is responsible for evaluating pre & post-service clinical service requests made by BCBSMA members and providers. The physician reviewer uses clinical judgment in conjunction with BCBSMA criteria to adjudicate these requests, engaging in peer-to-peer outreach with treating providers, as appropriate. At the request of the Medical Director of the Physician Review Unit (PRU), the reviewer also provides clinical leadership to other areas of BCBSMA.

The Team As an integral part of the Physician Review Unit within HMM (Health and Medical management), the physician reviewer reports to the Medical director and works with a team of actively practicing board certified physicians from a variety of specialties while collaborating with and providing clinical support across the company.

Key Responsibilities

• Analyze available clinical documentation including peer-to-peer outreach when appropriate then apply BCBSMA criteria and guidelines to determine if coverage of a requested service is medically necessary.
• Document coverage decisions in the BCBSMA utilization management system, to clearly outline the medical decision making involved and form the basis for provider and member letters.
• Complete coverage determinations in a timely fashion to meet unit productivity guidelines and NCQA, MCRA, FEP, Medicare and other applicable regulatory and accreditation standards.
• Work as part of the PRU team, sharing ideas, communicating best practices, identifying opportunities for unit effectiveness, and creating a positive work environment.
• Actively participate in all unit quality improvement activities.

Key Qualifications

• Leadership skills, including the ability to motivate and develop staff.
• Excellent collaboration, negotiation, and written communication skills.
• Ability to manage conflict effectively over the phone to maintain respectful and professional discourse.
• Effective and demonstrated oral communication and active listening skills.

Education and Experience

• MD or DO degree with an active specialty board certification.
• Current and valid, unrestricted license to practice medicine in the state of Massachusetts.
• Active clinical practice necessary to process appeals.
• Experience in Utilization Management in a managed-care or risk contract environment (committee work, large group practice, or peer review).

Minimum Education Requirements

High school degree or equivalent required unless otherwise noted above.

Location

Hingham

Time Type

Full time

Salary Range

$230,850.00 - $282,150.00

The job posting range is the lowest to highest salary we in good faith believe we would pay for this role at the time of this posting. We may ultimately pay more or less than the posted range, and the range may be modified in the future. An employee’s pay position within the salary range will be based on several factors including, but limited to, relevant education, qualifications, certifications, experience, skills, performance, shift, travel requirements, sales or revenue-based metrics, and business or organizational needs and affordability. This job is also eligible for variable pay.

Benefits

We offer comprehensive package of benefits including paid time off, medical/dental/vision insurance, 401(k), and a suite of well-being benefits to eligible employees.

Note: No amount of pay is considered to be wages or compensation until such amount is earned, vested, and determinable. The amount and availability of any bonus, commission, or any other form of compensation that are allocable to a particular employee remains in the Company's sole discretion unless and until paid and may be modified at the Company’s sole discretion, consistent with the law.

WHY Blue Cross Blue Shield of MA?

The more voices we have represented and amplified in our business, the more we will all thrive, contribute, and be brilliant. We encourage you to bring us your true colors, , your perspectives, and your experiences. It’s in our differences that we will remain relentless in our pursuit to transform healthcare for ALL.

Company Culture

As an employer, we are committed to investing in your development and providing the necessary resources to enable your success. Learn how we are dedicated to creating an inclusive and rewarding workplace that promotes excellence and provides opportunities for employees to forge their unique career path by visiting our Company Culture page.

Work-Life Balance

At Blue Cross Blue Shield of Massachusetts, we believe in wellness and that work/life balance is a key part of associate wellbeing. For more information on how we work and support that work/life balance visit our "How We Work" Page.

Recognition

Voted as the highest in member satisfaction among Massachusetts commercial health plans by JD Power, Blue Cross Blue Shield of Massachusetts is a community-focused, tax-paying, not-for-profit health plan headquartered in Boston.

We have been a market leader for over 75 years, and are consistently ranked among the nation's best health plans. Our daily efforts are dedicated to effectively serving our 2.8 million members, and consistently offering security, stability, and peace of mind to both our members and associates.

Commitment to You

We are committed to investing in your development and providing the necessary resources to enable your success. We are dedicated to creating a refreshing and rewarding workplace that promotes excellence and provides opportunities for employees to forge their unique career path. We take pride in our diverse, community-centric, wellness-focused culture and believe every member of our team deserves to enjoy a positive work-life balance.

Equal Employment Opportunity

Blue Cross Blue Shield of Massachusetts is an Equal Employment Employer - veterans/disability.

Applicants are considered for all positions without regard to race, color, religion, sex, national origin, age, veteran status, disability, sexual orientation, gender identity or expression, or any other characteristics protected by law.

Blue Cross Blue Shield of Massachusetts will not discharge or in any other manner discriminate against employees or applicants because they have inquired about, discussed, or disclosed their own pay or the pay of another employee or applicant.

However, employees who have access to the compensation information of other employees or applicants as a part of their essential job functions cannot disclose the pay of other employees or applicants to individuals who do not otherwise have access to compensation information, unless the disclosure is (a) in response to a formal complaint or charge, (b) in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or (c) consistent with Blue Cross Blue Shield of Massachusetts's legal duty to furnish information.