Blue Cross Blue Shield of Massachusetts · 9 hours ago
PT Utilization Management Reviewer
Hingham, MA
Full-time
Hybrid
Mid Level
$42.18/hr - $51.56/hr
3+ years expBlue Cross Blue Shield of Massachusetts is dedicated to transforming healthcare and is seeking a PT Utilization Management Reviewer. This role involves facilitating care for members with complex healthcare needs and authorizing medically necessary services while collaborating with a team of healthcare professionals.
AssociationCommunitiesHealth InsuranceInsuranceMedicalNon Profit
Responsibilities
Conduct pre-certification, concurrent, and retrospective reviews with emphasis on utilization management, discharge planning, care coordination, clinical outcomes, and quality of service
Evaluate members’ clinical status, benefits, and appropriateness for programs and sites of service to develop a cost-effective, medically necessary plan of care
Passed annual InterQual Interrater Reliability Test
Interact with treatment providers, PCPs, physicians, therapists, and facilities needed to gather clinical information to support the care plan
Monitor clinical quality concerns, make referrals appropriately, identify and escalate quality of care issues
Understand member insurance products and benefits, as well as regulatory and NCQA requirements
Qualification
Required
Self-directed, independent, adaptive, flexible to change, and able to collaborate as a member of a team
Ability to assess, analyze, draw conclusions, and construct effective solutions
Proficient with multiple IT systems
Demonstration of awareness, attitude, knowledge, and skills needed to work effectively with a culturally and demographically diverse population
3-5 years relevant experience in a variety of appropriate clinical health care settings (inpatient, outpatient, or differing levels of care)
Active licensure in Massachusetts is required, appropriate to position (PT)
Credentials: Doctor of Physical Therapy (DPT) degree, Master's in Physical Therapy (MSPT) or Bachelor's in Physical Therapy (BSPT) from a program accredited by the Commission on Accreditation in Physical Therapy Education (CAPTE)
High school degree or equivalent required unless otherwise noted above
Preferred
Utilization Management experience, preferred
Licensure in additional states a plus
Benefits
Paid time off
Medical/dental/vision insurance
401(k)
A suite of well-being benefits to eligible employees
Company
Blue Cross Blue Shield of Massachusetts
Blue Cross Blue Shield of Massachusetts is a state licensed private health insurance company
1001-5000 employees
Funding
Current Stage
Late StageLeadership Team
Sarah Iselin
President and Chief Executive Officer
Sophie Clarke
Chief Strategy Officer
Recent News
2025-12-09
2025-11-24
Boston Globe
2025-11-14
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