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