Blue Cross Blue Shield of Massachusetts · 8 hours ago

Utilization Management Reviewer – Behavioral Health – Part Time

Hingham, MA

Part-time

Remote

Mid Level

$37.43/hr - $45.75/hr

3+ years exp

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Responsibilities

Conduct pre-certification and concurrent and retrospective clinical review of in-state and out-of-state inpatient cases, residential treatment programs, partial hospitalization, intensive outpatient programs and other outpatient services through the application of evidence-based medical necessity criteria and BCBSMA policies and procedures

Focus on efficient utilization management with emphasis on discharge planning

Understand and appropriately manages member's benefits to maximize health care quality

Collaborate with physician reviewers, case managers, project leaders and associates within BCBSMA to optimize member care and ensure a constructive provider experience

Facilitate review process by communication with members/families, providers, medical staff and/or others to obtain and/or share information relating to benefits and the BCBSMA utilization management process

Collaborate with members/families, providers, medical staff and/or other members of the treatment team to coordinate and support health action plans developed by providers that include treatment goals, interventions, and expected clinical outcomes and that support quality and medical management goals and objectives

Identify and refer members who may benefit from high-risk case management and disease state management intervention

Maintain professional licensure and seeks out continuous learning opportunities to enhance understanding of clinical management, trends in patient care, utilization management and other topics applicable to carrying out job responsibilities in an educated manner

Utilize the computer systems to efficiently enter case information, check benefits and eligibility, look up policy and procedures, validate provider contractual status and other functions relating to the execution of key responsibilities

Exhibit customer satisfaction orientation in every aspect of carrying out responsibilities

Meet or exceed annual performance goal of 90% cumulatively for case audits and recorded call audits, where applicable

Other responsibilities as assigned by management

Qualification

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Behavioral Health KnowledgeClinical ExperienceIndependent LicensureUtilization ManagementInterQual CertificationCustomer Service SkillsMicrosoft WordMicrosoft ExcelMicrosoft OutlookMedHOK FamiliarityCCM CertificationProblem-Solving Ability