Physician Reviewer & Clinical Leadership (Utilization)

Physician Pivot; Hingham (MA); On-site; USD 231,000 - 282,000; Full time

Benefits offered by this job

Paid time off

Medical/dental/vision insurance

401(k)

Well-being benefits

Variable pay eligibility

Job summary

Blue Cross Blue Shield of Massachusetts seeks a physician reviewer in the Physician Review Unit (PRU) to adjudicate pre- and post-service requests for BCBSMA members. You will use clinical judgment, engage in peer-to-peer outreach, and provide clinical leadership as directed by the Medical Director.

The role requires an MD/DO with board certification, an active MA license, and experience in utilization management within managed-care settings.

Qualifications

• MD or DO with board certification required.
• Current and valid Massachusetts medical license.
• Active clinical practice necessary to process appeals.
• Experience in Utilization Management in a managed-care environment.

Responsibilities

• Analyze available clinical documentation and apply BCBSMA criteria to determine medical necessity.
• Document coverage decisions in the UM system with clear justification for letters to providers and members.
• Complete coverage determinations timely to meet NCQA, MCRA, FEP, Medicare and other standards.
• Collaborate as part of the Physician Review Unit (PRU) team and share best practices.
• Participate in unit quality improvement activities.

Skills

Leadership

Collaboration

Negotiation

Written communication

Conflict management

Active listening

Education

MD or DO with board certification

Massachusetts medical license

Active clinical practice to process appeals

Utilization Management in managed-care

Job description

Blue Cross Blue Shield of Massachusetts seeks a physician reviewer in the Physician Review Unit (PRU) to adjudicate pre- and post-service requests for BCBSMA members. You will use clinical judgment, engage in peer-to-peer outreach, and provide clinical leadership as directed by the Medical Director.

The role requires an MD/DO with board certification, an active MA license, and experience in utilization management within managed-care settings.