Clinical Utilization Reviewer, LPN

Ready to help us transform healthcare? Bring your true colors to blue. Key Responsibilities: Conduct pre-certification, concurrent, and retrospective reviews with emphasis on utilization management, discharge planning, care coordination, clinical outcomes, and quality of service by applying industry standard criteria (Interqual in use in 2023 ) and BCBSMA medical policies for defined service requests. Evaluate members’ clinical status, benefits, and appropriateness for programs and sites of service to develop a cost-effective, medically necessary plan of care. Pass annual InterQual Interrater Reliability Test. Interact with treatment providers, PCPs, physicians, therapists, and facilities as needed to gather clinical information to support the plan of care. Monitor clinical quality concerns, make referrals appropriately, identify and escalate quality of care issues, specifically related to outlier cases, long LOS cases or complicated prior authorization requests Understand member insurance products and benefits, as well as regulatory and NCQA requirements. Refer to RN or PT Clinical Utilization reviewer for more complex cases as appropriate or when question of potential denial of services is identified. Refer to Physician Review Unit (PRU) for potential denial of prior authorization requests with complete data to support reason for PRU referral. Collaborate within a team of professionals, including clinical care managers, account representatives, member service associates, to provide members and providers with a high level of benefits education, and BCBSMA medical policy requirements related to prior authorization requirements. Interact with external facility or providers as needed to gather clinical information to support the medical necessity review process and plan of care. Support a positive workplace environment, collaborate, and share clinical knowledge and skills to support our culturally and demographically diverse member population. Other clinical duties as assigned. Key Qualifications: Self-directed, independent, adaptive, flexible to change, and able to collaborate as a member of a team. Ability to assess clinical documentation, analyze, draw conclusions, and construct effective recommendations for authorization or care management services. Proficient with multiple IT systems, demonstrates strong digital skills based on prior roles. Demonstration of awareness, attitude, knowledge, and skills needed to work effectively with a culturally and demographically diverse population Education and Experience: 3-5 years relevant experience in a variety of appropriate clinical health care settings (Inpatient, outpatient, or skilled nursing levels of care). Utilization Management experience preferred Active licensure in Massachusetts is required, appropriate to position -LPN Licensure in additional states a plus. Note: Any restrictions against a license must be disclosed and reviewed. This role is eligible for our eWorker, Mobile, and Resident personas. This position can be fully remote, with expectations to work in our Hingham, MA office 1-3X a month #LI-HYBRID Minimum Education Requirements: High school degree or equivalent required unless otherwise noted above Location Hingham Time Type Full time Hourly Range: $31.94 - $39.04 The job posting range is the lowest to highest salary we in good faith believe we would pay for this role at the time of this posting. We may ultimately pay more or less than the posted range, and the range may be modified in the future. An employee’s pay position within the salary range will be based on several factors including, but limited to, relevant education, qualifications, certifications, experience, skills, performance, shift, travel requirements, sales or revenue-based metrics, and business or organizational needs and affordability. This job is also eligible for variable pay. We offer comprehensive package of benefits including paid time off, medical/dental/vision insurance, 401(k), and a suite of well-being benefits to eligible employees. Note: No amount of pay is considered to be wages or compensation until such amount is earned, vested, and determinable. The amount and availability of any bonus, commission, or any other form of compensation that are allocable to a particular employee remains in the Company's sole discretion unless and until paid and may be modified at the Company’s sole discretion, consistent with the law. WHY Blue Cross Blue Shield of MA? We understand that the confidence gap and imposter syndrome can prevent amazing candidates coming our way, so please don’t hesitate to apply. We’d love to hear from you. You might be just what we need for this role or possibly another one at Blue Cross Blue Shield of MA. The more voices we have represented and amplified in our business, the more we will all thrive, contribute, and be brilliant. We encourage you to bring us your true colors, , your perspectives, and your experiences. It’s in our differences that we will remain relentless in our pursuit to transform healthcare for ALL. As an employer, we are committed to investing in your development and providing the necessary resources to enable your success. Learn how we are dedicated to creating an inclusive and rewarding workplace that promotes excellence and provides opportunities for employees to forge their unique career path by visiting our Company Culture page. If this sounds like something you’d like to be a part of, we’d love to hear from you. You can also join our Talent Community to stay “in the know” on all things Blue. At Blue Cross Blue Shield of Massachusetts, we believe in wellness and that work/life balance is a key part of associate wellbeing. For more information on how we work and support that work/life balance visit our "How We Work" Page. 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.

Salary : $32 - $39