Clinical Service Evaluator

Job Summary

We are seeking a highly skilled Clinical Service Evaluator to join our team at Blue Cross Blue Shield of Massachusetts. As a key member of our Physician Review Unit, you will play a crucial role in evaluating pre- and post-service clinical service requests made by BCBSMA members and providers.

In this position, you will utilize your clinical judgment in conjunction with BCBSMA criteria to adjudicate these requests, engaging in peer-to-peer outreach with treating providers as needed. Your expertise will also be utilized to provide clinical leadership in other areas of BCBSMA, working closely with the Senior Medical Director to identify opportunities for improved care coordination and health outcomes.

This is an exciting opportunity for a motivated and detail-oriented professional to make a meaningful impact on the lives of our members. If you are passionate about transforming healthcare and have a strong background in clinical evaluation and leadership, we encourage you to apply. ? Key Responsibilities: ? Apply BCBS Criteria and guidelines to case reviews of BCBS members to determine coverage of requested services ? Assess available clinical documentation and identify missing information necessary for coverage determinations ? Document critical activities relating to coverage decisions in the BCBSMA utilization management system (MHK) ? Complete coverage determinations in a timely fashion to meet regulatory, accreditation, and unit productivity guidelines ? Work collaboratively with the PRU team to share ideas, best practices, and identify opportunities for unit effectiveness

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