Utilization Management Reviewer

Transforming Healthcare Together

The Clinical Utilization Reviewer plays a crucial role in facilitating care for members with complex healthcare needs. This position is self-directed, working independently and collaboratively to promote optimal health through clinical skills, managed care principles, and nationally recognized medical necessity criteria.

About the Role
• Conduct pre-certification and concurrent retrospective reviews of inpatient cases, residential treatment programs, partial hospitalization, intensive outpatient programs, and other services using evidence-based medical necessity criteria and BCBSMA policies.
• Focus on efficient utilization management with emphasis on discharge planning.
• Understand and manage member benefits to maximize healthcare quality.
• Collaborate with physician reviewers, case managers, project leaders, and associates to optimize member care and ensure a constructive provider experience.
• Facilitate review process through communication with members, families, providers, medical staff, and others to obtain and share information regarding benefits and the BCBSMA utilization management process.
• Collaborate with members, families, providers, medical staff, and other team members to coordinate and support health action plans that include treatment goals, interventions, and expected outcomes.
• Identify and refer members who may benefit from high-risk case management and disease state management intervention.
• Maintain professional licensure and seek continuous learning opportunities to enhance understanding of clinical management, patient care trends, and utilization management.
• Utilize computer systems to efficiently enter case information, check benefits, look up policies, validate provider status, and perform other key functions.
• Exhibit customer satisfaction orientation in all aspects of responsibilities.
• Meet or exceed annual performance goals for case audits and recorded call audits.
• Other responsibilities as assigned by management.

We're Looking For:
• Solid clinical knowledge in Behavioral Health, with specialty knowledge a plus.
• Excellent organizational skills, ability to manage multiple ongoing tasks.
• Strong problem-solving ability under pressure of timeliness turnaround deadlines.
• Excellent communication skills, able to discuss sensitive/ confidential information in a professional, unbiased manner.
• Proven customer service skills.
• Intermediate ease of use with computers and familiarity with common software like Microsoft Word, Excel, and Outlook.
• Ability to integrate into a working team and function independently to complete assigned workload.
• Achieve a passing score on the yearly InterQual, behavioral health medical necessity criteria, interrater reliability test.
• Familiarity with our utilization management system, MedHOK.

What You Bring:
• Behavioral Health professional with an active independent Massachusetts license: Registered Nurse, LICSW, LMHC, BCBA.
• 3-5 years of clinical experience in Behavioral Health Care settings.
• Utilization Management experience preferred.
• CCM or other applicable certification(s) desirable.

Minimum Education Requirements: High school degree or equivalent required unless otherwise noted above Location: Hingham Time Type: Part time Hourly Range: $37.43 - $45.75

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