Clinical Utilization Reviewer, LPN
About the position
Ready to help us transform healthcare? Bring your true colors to blue. This role involves conducting pre-certification, concurrent, and retrospective reviews with an emphasis on utilization management, discharge planning, care coordination, clinical outcomes, and quality of service by applying industry standard criteria (Interqual in use in 2023) and BCBSMA medical policies for defined service requests. You will evaluate members' clinical status, benefits, and appropriateness for programs and sites of service to develop a cost-effective, medically necessary plan of care. The position requires interaction with treatment providers, PCPs, physicians, therapists, and facilities to gather clinical information to support the plan of care, as well as monitoring clinical quality concerns and making appropriate referrals. This role supports a positive workplace environment and collaborates with a diverse member population.
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.
,
Pass annual InterQual Interrater Reliability Test.
,
Interact with treatment providers, PCPs, physicians, therapists, and facilities to gather clinical information.
,
Monitor clinical quality concerns and make referrals appropriately.
,
Understand member insurance products and benefits, as well as regulatory and NCQA requirements.
,
Refer to RN or PT Clinical Utilization reviewer for complex cases.
,
Refer to Physician Review Unit (PRU) for potential denial of prior authorization requests.
,
Collaborate within a team of professionals to provide members and providers with benefits education.
,
Interact with external facility or providers to gather clinical information.
,
Support a positive workplace environment and collaborate to support a diverse member population.
,
Perform other clinical duties as assigned.
Requirements
3-5 years relevant experience in a variety of appropriate clinical health care settings.
,
Utilization Management experience preferred.
,
Active licensure in Massachusetts as LPN.
,
Licensure in additional states is a plus.
,
Self-directed, independent, adaptive, flexible to change, and able to collaborate as a team member.
,
Ability to assess clinical documentation and construct effective recommendations.
,
Proficient with multiple IT systems and demonstrates strong digital skills.
,
Demonstration of awareness, attitude, knowledge, and skills needed to work effectively with a diverse population.
Nice-to-haves
Benefits
Paid time off
,
Medical/dental/vision insurance
,
401(k)
,
Suite of well-being benefits
Apply Now
Ready to help us transform healthcare? Bring your true colors to blue. This role involves conducting pre-certification, concurrent, and retrospective reviews with an emphasis on utilization management, discharge planning, care coordination, clinical outcomes, and quality of service by applying industry standard criteria (Interqual in use in 2023) and BCBSMA medical policies for defined service requests. You will evaluate members' clinical status, benefits, and appropriateness for programs and sites of service to develop a cost-effective, medically necessary plan of care. The position requires interaction with treatment providers, PCPs, physicians, therapists, and facilities to gather clinical information to support the plan of care, as well as monitoring clinical quality concerns and making appropriate referrals. This role supports a positive workplace environment and collaborates with a diverse member population.
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.
,
Pass annual InterQual Interrater Reliability Test.
,
Interact with treatment providers, PCPs, physicians, therapists, and facilities to gather clinical information.
,
Monitor clinical quality concerns and make referrals appropriately.
,
Understand member insurance products and benefits, as well as regulatory and NCQA requirements.
,
Refer to RN or PT Clinical Utilization reviewer for complex cases.
,
Refer to Physician Review Unit (PRU) for potential denial of prior authorization requests.
,
Collaborate within a team of professionals to provide members and providers with benefits education.
,
Interact with external facility or providers to gather clinical information.
,
Support a positive workplace environment and collaborate to support a diverse member population.
,
Perform other clinical duties as assigned.
Requirements
3-5 years relevant experience in a variety of appropriate clinical health care settings.
,
Utilization Management experience preferred.
,
Active licensure in Massachusetts as LPN.
,
Licensure in additional states is a plus.
,
Self-directed, independent, adaptive, flexible to change, and able to collaborate as a team member.
,
Ability to assess clinical documentation and construct effective recommendations.
,
Proficient with multiple IT systems and demonstrates strong digital skills.
,
Demonstration of awareness, attitude, knowledge, and skills needed to work effectively with a diverse population.
Nice-to-haves
Benefits
Paid time off
,
Medical/dental/vision insurance
,
401(k)
,
Suite of well-being benefits
Apply Now