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Blue Cross Blue Shield of Massachusetts RN Utilization Management Reviewer I Registered Nurse in Quincy, Massachusetts

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The RN Utilization Management Reviewer uses clinical skills, principals of managed care, nationally recognized medical necessity criteria, Center for Medicare and Medicaid (CMS) guidelines, company medical policies, and collaborative work with the clinical support staff and provider community to conduct reviews that promote efficient and medically appropriate use of the member's benefit in order to achieve cost effective and quality outcomes.The RN Utilization Management Reviewer focuses on authorizing medically necessary services at the right level of care. The RN Utilization Management Reviewer works primarily by telephone, and in partnership with the treating clinician or facility case manager, to ensure all required information is received in order to make a timely decision and to ensure that a coordinated discharge plan is in place.The RN Utilization Management Reviewer is able to effectively work independently as well as collaboratively within a highly matrixed environment. The RN Utilization Management Reviewer demonstrates understanding of the principles of managed care, department business objectives and measures.

KEY RESPONSIBILITIES :

  • Conduct pre-certification, concurrent, and retrospective reviews when indicated and as allowed, for applicable product lines and levels of care, with emphasis on utilization management, discharge planning, coordination of services, clinical outcomes, and quality of services

  • Evaluation of member's clinical status, benefit plan /product, and appropriateness for internal and external programs and sites of service in order to facilitate determination of cost-effective, medically necessary plan of care

  • Interaction with treatment providers, PCPs, physicians, therapists, and facilities, as needed to gather clinical information support the plan of care

  • Regular interactions with case managers, supervisors, managers, and physicians to discuss level of care questions, concerns, discharge needs, and barriers to achieving the most cost-effective, medically appropriate plan of care .

  • Presentation of cases at rounds, during on site consultant /account assessments and follow-up with physicians as necessary to obtain physician input and achieve optimal outcomes

QUALIFICATIONS & SKILLS:

  • Ability to adapt and be flexible to change as priorities within this environment change constantly

  • Willingness to learn new skills from both a business and clinical perspective

  • Strong teamwork and communication skills as well as ability to be self-directive

  • Ability to analyze information to construct effective solutions

  • Execution and results (ability to set goals, follow processes, meet deadlines, and deliver expected outcomes with appropriate sense of urgency)

  • Cultural competence (demonstration of awareness, attitude, knowledge, and skills to work effectively with a culturally and demographically diverse population)

  • Clinical assessment (ability to interpret, evaluate, and clearly document complex medical information using a directive and focused approach in order to identify relevant and actionable conditions, circumstances, and behaviors)

  • Care planning (ability to identify and clearly document member-driven, specific, measurable activities that address actionable conditions, circumstances, and behaviors in order to improve health outcomes and cost-effectiveness of services)

  • Member collaboration and engagement (ability to secure and maintain the motivation, participation, and collaboration of all relevant parties in a purposeful plan to improve health outcomes and cost-effectiveness of service delivery)

EDUCATION & RELEVANT EXPERIENCE:

  • Minimum 3-5 years of Registered Nurse experience and have worked in one or more in the following settings within the last 12 months : Medical-Surgical, Critical Care, Telemetry/Cardiac, Emergency or Sub-acute/Skilled/Rehabilitation unit

  • Active Massachusetts RN license; Licensure in additional states a plus. Note: any restrictions against a license must be disclosed and reviewed

  • Utilization Management experience, preferred

  • Knowledge of managed care plans and health insurance experience, a plus

  • Bachelor’s degree preferred in nursing, masters a plus

  • Ability to demonstrate proficiency with multiple Information Technology systems

Minimum Education Requirements:

High school degree or equivalent required

LocationQuincyTime TypeFull time

At Blue Cross Blue Shield of Massachusetts, we believe in wellness and that work/life balance is a key part of associate wellbeing. We provide a flexible hybrid work model in which roles are designated as resident (on site 4-5 days/week), mobile (on site 1-3 days/week), or eworker (on site 0-3 days/month).

Blue Cross Blue Shield of Massachusetts, has a COVID-19 vaccination requirement for building entry. Your offer of employment is dependent upon either being fully vaccinated for COVID-19, or receiving an eworker exemption and/or accommodation based on a disability or sincerely held religious belief, practice, or observance by submitting a request to Human Resources.

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.

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