Physician Reviewer - Utilization Management

Blue Cross and Blue Shield of Massachusetts Inc.; Hingham (MA); Vor Ort; USD 231.000 - 282.000; Vollzeit

Zusammenfassung

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

Qualifikationen

• 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.

Aufgaben

• 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.

Kenntnisse

Leadership

Collaboration & negotiation

Written communication

Oral communication & listening

Ausbildung

MD or DO with board certification

MA medical license

Active clinical practice for appeals

Utilization Management experience

High school degree or equivalent

Jobbeschreibung

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