Telephonic Reviewer

Today's healthcare industry -- dynamic and changing at a fast pace. Recruiting talented people can mean the difference between success or failure. At Blue Cross and Blue Shield of Massachusetts, our record of achievement represents a history of hiring the best people we can find, and then challenging them to excel. It's the kind of environment that enables us to give our best to the consumers we serve, and at the same time, work to the potential of those who work for us.

Reviewer II

Blue Cross Blue Shield of Massachusetts is an Equal Opportunity 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, or any other characteristics protected by law.

Major Responsibilities:

Conducts pre-certification, concurrent and retrospective clinical review of in state and out of state inpatient cases at acute, rehabilitation and skilled nursing facilities though application of evidence-based medical necessity criteria, BCBSMA policies and procedures and other applicable policies and guidelines in compliance with regulatory and legislative requirements.

Focuses on efficient utilization management with emphasis on discharge planning. Case management components may be required.

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

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

Facilitates 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.

Collaborates with members/families, providers, medical staff and/or other members of the treatment team in order to develop, implement/authorize, and document treatment plans that include treatment goals, interventions, and expected clinical outcomes.

Identifies and refers members who may benefit from high-risk case management and disease state management intervention.

Educates and support members/families regarding benefits, eligibility, BCBSMA policies and processes with the goal to empower self-advocacy.

Maintains 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.

Utilizes 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.

Exhibits customer satisfaction orientation in every aspect of carrying out responsibilities

Completes cost avoidance and other reports and tracking tools to capture impact and/or scope of medical management responsibilities.

Other responsibilities as assigned by management.

Qualifications (Knowledge, skills and abilities):

Solid clinical knowledge in general medical/surgical arena. Specialty knowledge a plus.

Excellent organizational skills, ability to manage multiple ongoing tasks

Strong problem-solving ability under pressure of timeliness turnaround deadlines

Excellent communication skills. Able to discuss sensitive / confidential information in a professional, unbiased manner.

Proven customer service skills. Works with providers and members to ensure satisfaction of interaction even though outcome may not be exactly what was desired/requested.

Basic to intermediate ease of use with computers and a working understanding of common computer software such as Microsoft Word, Excel and Outlook.

Ability to integrate as part of a working team, and also function independently to complete assigned workload.

Yearly certification in MCAP criteria required.


Registered Nurse with an active professional Massachusetts license

3-5 years of clinical experience in medical/surgical acute care settings. Sub-acute/Skilled/Rehabilitation care experience desirable.

Bachelor's Degree in Nursing or health-related field preferred

Utilization Management experience preferred

Case management experience desirable

CCM, CPUR, CPUM or other applicable certification(s) desirable.