RN Utilization Management Reviewer

Blue Cross MA; Hingham (MA); On-site; USD 54,000 - 66,000; Full time

Benefits offered by this job

PTO

Medical Insurance

Dental Insurance

Vision Insurance

401(k)

Well-being benefits

Job summary

Blue Cross and Blue Shield of Massachusetts Inc. in Hingham is seeking an RN Utilization Management Reviewer to help manage member care.

The role requires independent work and collaboration with a team of clinicians to authorize medically necessary services at the right level of care. You will conduct pre-certification, concurrent and retrospective reviews, evaluate clinical status, and coordinate with providers to develop cost-effective, medically appropriate plans of care.

Qualifications

• 3-5 years relevant experience in clinical health care settings (inpatient, outpatient, or varied levels of care).
• Utilization Management experience preferred.
• Active RN licensure in Massachusetts; BSN preferred.

Responsibilities

• Conduct pre-certification, concurrent, and retrospective reviews focused on utilization management, discharge planning, care coordination and quality of service.
• Evaluate members' clinical status, benefits, and appropriateness for programs/sites of service to develop cost-effective, medically necessary care plans.
• Pass InterQual Interrater Reliability Test.
• Interact with providers to gather clinical information to support the plan of care.
• Monitor quality concerns and escalate issues as needed.
• Understand member insurance products and regulatory and NCQA requirements.

Skills

Self-directed

Independent

Adaptive

Collaborative

IT systems proficiency

Education

High school degree or equivalent

Registered Nurse licensure MA

BSN preferred

Job description

RN Utilization Management Reviewer### RN Utilization Management ReviewerApply: Hingham: Full time: Posted 2 Days Ago: R09065## **Ready to help us transform healthcare? Bring your true colors to blue.****The Role** The Clinical Utilization Reviewer is responsible for facilitating care for members who may have complex healthcare needs, authorizing medically necessary services at the right level of care to promote optimal health.This position is self-directed and works independently and collaboratively to facilitate care using clinical skills, principles of managed care, nationally recognized medical necessity criteria, and company medical policies to conduct reviews that promote efficient and medically appropriate use of the member’s benefit to provide the best quality care. **The Team** The Clinical Utilization Reviewer is part of a highly dedicated and motivated team of professionals, including medical and behavioral health care managers, dieticians, pharmacist, clinicians, medical directors and more, who collaborate to facilitate care. **Key Responsibilities:*** Conduct pre-certification, concurrent, and retrospective reviews with emphasis on utilization management, discharge planning, care coordination, clinical 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 as needed to gather clinical information to support the plan of care.* Monitor clinical quality concerns, make referrals appropriately, identify and escalate quality of care issues.* Understand member insurance products and benefits, as well as regulatory and NCQA requirements. **Key Qualifications:*** Self-directed, independent, adaptive, flexible to change, and able to collaborate as a member of a team.* Ability to assess, analyze, draw conclusions, and construct effective solutions.* Proficient with multiple IT systems.* Demonstration of awareness, attitude, knowledge, and skills needed to work effectively with a culturally and demographically diverse population. **Education and Experience:*** 3-5 years relevant experience in a variety of appropriate clinical health care settings (Inpatient, outpatient, or differing levels of care).* Utilization Management experience, preferred* Active licensure in Massachusetts is required, appropriate to position (RN) + Licensure in additional states a plus. + Note: Any restrictions against a license must be disclosed and reviewed. + For Registered Nurses Only: A Bachelor’s degree in nursing (BSN) is preferred## Minimum Education Requirements:High school degree or equivalent required unless otherwise noted above## LocationHingham## Time TypeFull timeHourly Range: $39.32 - $48.06 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.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.