Clinical Utilization Reviewer, LPN

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

High school degree or equivalent required unless otherwise noted above

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 theconfidence gapandimposter syndromecan 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 ourCompany Culturepage. If this sounds like something you'd like to be a part of, we'd love to hear from you. You can also join ourTalent Communityto 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.