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
Ā 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.
Ā Focus on efficient utilization management with emphasis on discharge planning.
Ā Understand and manage member benefits to maximize healthcare quality.
Ā Collaborate with physician reviewers, case managers, project leaders, and associates to optimize member care and ensure a constructive provider experience.
Ā 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.
Ā 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.
Ā Identify and refer members who may benefit from high-risk case management and disease state management intervention.
Ā Maintain professional licensure and seek continuous learning opportunities to enhance understanding of clinical management, patient care trends, and utilization management.
Ā Utilize computer systems to efficiently enter case information, check benefits, look up policies, validate provider status, and perform other key functions.
Ā Exhibit customer satisfaction orientation in all aspects of responsibilities.
Ā Meet or exceed annual performance goals for case audits and recorded call audits.
Ā Other responsibilities as assigned by management.
We're Looking For:
Ā Solid clinical knowledge in Behavioral Health, with specialty knowledge a plus.
Ā Excellent organizational skills, ability to manage multiple ongoing tasks.
Ā Strong problem-solving ability under pressure of timeliness turnaround deadlines.
Ā Excellent communication skills, able to discuss sensitive/ confidential information in a professional, unbiased manner.
Ā Proven customer service skills.
Ā Intermediate ease of use with computers and familiarity with common software like Microsoft Word, Excel, and Outlook.
Ā Ability to integrate into a working team and function independently to complete assigned workload.
Ā Achieve a passing score on the yearly InterQual, behavioral health medical necessity criteria, interrater reliability test.
Ā Familiarity with our utilization management system, MedHOK.
What You Bring:
Ā Behavioral Health professional with an active independent Massachusetts license: Registered Nurse, LICSW, LMHC, BCBA.
Ā 3-5 years of clinical experience in Behavioral Health Care settings.
Ā Utilization Management experience preferred.
Ā 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
Apply Now
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
Ā 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.
Ā Focus on efficient utilization management with emphasis on discharge planning.
Ā Understand and manage member benefits to maximize healthcare quality.
Ā Collaborate with physician reviewers, case managers, project leaders, and associates to optimize member care and ensure a constructive provider experience.
Ā 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.
Ā 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.
Ā Identify and refer members who may benefit from high-risk case management and disease state management intervention.
Ā Maintain professional licensure and seek continuous learning opportunities to enhance understanding of clinical management, patient care trends, and utilization management.
Ā Utilize computer systems to efficiently enter case information, check benefits, look up policies, validate provider status, and perform other key functions.
Ā Exhibit customer satisfaction orientation in all aspects of responsibilities.
Ā Meet or exceed annual performance goals for case audits and recorded call audits.
Ā Other responsibilities as assigned by management.
We're Looking For:
Ā Solid clinical knowledge in Behavioral Health, with specialty knowledge a plus.
Ā Excellent organizational skills, ability to manage multiple ongoing tasks.
Ā Strong problem-solving ability under pressure of timeliness turnaround deadlines.
Ā Excellent communication skills, able to discuss sensitive/ confidential information in a professional, unbiased manner.
Ā Proven customer service skills.
Ā Intermediate ease of use with computers and familiarity with common software like Microsoft Word, Excel, and Outlook.
Ā Ability to integrate into a working team and function independently to complete assigned workload.
Ā Achieve a passing score on the yearly InterQual, behavioral health medical necessity criteria, interrater reliability test.
Ā Familiarity with our utilization management system, MedHOK.
What You Bring:
Ā Behavioral Health professional with an active independent Massachusetts license: Registered Nurse, LICSW, LMHC, BCBA.
Ā 3-5 years of clinical experience in Behavioral Health Care settings.
Ā Utilization Management experience preferred.
Ā 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
Apply Now