Clinical Utilization Specialist

Transforming Healthcare with Blue Cross Blue Shield of Massachusetts

At Blue Cross Blue Shield of Massachusetts, we are seeking a skilled Clinical Utilization Specialist to join our team. As a key member of our healthcare transformation initiative, you will play a vital role in ensuring the efficient and medically appropriate use of benefits to provide the best quality care for our members.

The ideal candidate will have strong clinical skills, experience working independently and collaboratively, and a working understanding of common computer software such as Microsoft Word, Excel, and Outlook. A background in managed care, medical necessity criteria, and company policies is also essential.

This part-time position offers a comprehensive package of benefits, including paid time off, medical/dental/vision insurance, 401(k), and a suite of well-being benefits to eligible employees. The estimated salary for this position is $37 per hour, based on relevant education, qualifications, certifications, experience, skills, performance, and business needs. We strive to maintain a work-life balance and offer a supportive environment that promotes professional growth and development.

Key Responsibilities: ? Conduct pre-certification, concurrent, and retrospective clinical reviews of in-state and out-of-state inpatient cases, residential treatment programs, partial hospitalization, intensive outpatient programs, and other outpatient services. ? Focus on efficient utilization management with an emphasis on discharge planning. ? Understand and appropriately manage member benefits to maximize healthcare quality. ? Collaborate with physician reviewers, case managers, project leaders, and associates within BCBSMA to optimize member care and ensure a constructive provider experience. ? Facilitate the review process by communicating with members/families, providers, medical staff, and/or others to obtain and/or share information relating to benefits and the BCBSMA utilization management process.

Required Skills and Qualifications: ? Intermediate ease of use with computers. ? A working understanding of common computer software such as Microsoft Word, Excel, and Outlook. ? Ability to discuss sensitive/confidential information in a professional, unbiased manner. ? Passing score on the yearly InterQual, behavioral health medical necessity criteria, interrater reliability test.

Benefits:

We offer a comprehensive package of benefits to eligible employees, including paid time off, medical/dental/vision insurance, 401(k), and a suite of well-being benefits. The estimated salary for this position is $37 per hour, based on relevant education, qualifications, certifications, experience, skills, performance, and business needs.

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