Blue Cross Blue Shield of Massachusetts RN Clinical Reviewer I MedSurg Registered Nurse I Utilization Management in Quincy, Massachusetts
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BCBSMA is seeking a new RN Clinical Reviewer for their elite Utilization Management Division!The Clinical Review Unit evaluates for clinical necessity, appropriateness and efficiency of health care services, procedures and settings requested for our members in our commercial accounts. Blue Cross and Blue Shield of Massachusetts uses medical technology, assessment criteria and medical necessity guidelines when developing a utilization review criteria or medical policy. The Clinical Reviewer focuses on authorizing medically necessary services at the right level of care. The Clinical Reviewer works primarily by telephone and in partnership with the treating clinician or facility case manager to ensure all required information is received to make a timely decision and ensure a coordinated discharge plan is in place. The clinical reviewer can work independently as well as collaboratively within a highly matrixed environment.
Conduct pre-certification, concurrent and retrospective reviews for our commercial accounts
Perform utilization management, discharge planning and coordination of services
Evaluation, monitoring and documenting plan of care
Evaluation of member's clinical status, benefit plan and appropriateness for care management services
Navigate clinical tools and information to conduct comprehensive assessment of member eligibility and health needs making consistent review decisions
Adherence to clinical criteria certifications, program, departmental and organizations performance standards including inter-rater reliability metrics
Interaction with treatment providers, PCPs and facilities as needed to support the plan of care
Regular interactions with supervisors, managers and physicians to discuss level of care questions, concerns, discharge needs and barriers to achieving the appropriate plan of care
Manage caseload in compliance with regulatory and accreditation requirements
Monitor clinical quality concerns and refer appropriately
Identify and escalate quality of care issues through established channels
Excellent organization and problem-solving skills
Excellent communications skills
Ability to work in a changing environment
Ability to prioritize and manage an assigned workload
Comfort and proficiency with computers and technology
Knowledge of regulatory and accreditation requirements
Education & Training:
Active MA RN License is required
Minimum 3-5 years of clinical experience medical surgical care setting, Sub-acute/Skilled/Rehabilitation care experience desirable
Bachelor's in Nursing (BSN) preferred, masters a plus
Utilization Management experience preferred
LocationQuincyTime TypeFull time
Voted as the highest in member satisfaction among Massachusetts commercial health plans by JD Power, Blue Cross Blue Shield of Massachusetts is a community-focused, tax-paying, not-for-profit health plan headquartered in Boston. We have been a market leader for over 75 years, and are consistently ranked among the nation's best health plans. Our daily efforts are dedicated to effectively serving our 2.8 million members, and consistently offering security, stability, and peace of mind to both our members and associates.
Our Commitment to You
We are committed to investing in your development and providing the necessary resources to enable your success. We are dedicated to creating a refreshing and rewarding workplace that promotes excellence and provides opportunities for employees to forge their unique career path. We take pride in our diverse, community-centric, wellness-focused culture and believe every member of our team deserves to enjoy a positive work-life balance.
Blue Cross Blue Shield of Massachusetts is an Equal Employment / Affirmative Action Employer. Applicants are considered for all positions without regard to race, color, religion, sex, national origin, age, veteran status, disability, sexual orientation, gender identity or expression, or any other characteristics protected by law.
Blue Cross Blue Shield of Massachusetts will not discharge or in any other manner discriminate against employees or applicants because they have inquired about, discussed, or disclosed their own pay or the pay of another employee or applicant. However, employees who have access to the compensation information of other employees or applicants as a part of their essential job functions cannot disclose the pay of other employees or applicants to individuals who do not otherwise have access to compensation information, unless the disclosure is (a) in response to a formal complaint or charge, (b) in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or (c) consistent with Blue Cross Blue Shield of Massachusetts's legal duty to furnish information.