RN Utilization Management Reviewer l Registered Nurse l Federal Employee Program at Blue Cross and Blue shield of Massachusetts, Inc. in Quincy, Massachusetts

Job Description:

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The 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 Utilization Management Reviewer focuses on authorizing medically necessary services at the right level of care. The 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 Utilization Management Reviewer is able to effectively work independently as well as collaboratively within a highly matrixed environment. The 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
- Will need to understand regulatory requirements for the Federal Employee Program

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 direct patient clinical experience: Medical-surgical care setting, Sub-acute/Skilled/Rehabilitation care experience desirable
- 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 in nursing, preferred; master's degree is a plus
- Ability to demonstrate proficiency with multiple Information Technology systems

LocationQuincyTime TypeFull time

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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.