Clinical Reviewer Jobs Vacancy in Blue Cross Shield Massachusetts Quincy
Blue Cross Shield Massachusetts Quincy urgently required following position for Clinical Reviewer. Please read this job advertisement carefully before apply. There are some qualifications, experience and skills requirement that the employers require. Does your career history fit these requirements? Ensure you understand the role you are applying for and that it is suited to your skills and qualifications.
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Clinical Reviewer Jobs Vacancy in Blue Cross Shield Massachusetts Quincy Jobs Details:
Are you looking for innovation? Your search is over - it happens here.The Clinical Reviewer uses clinical skills, principals of managed care, nationally recognized medical necessity criteria, company medical policies, and collaborative work with the clinical support staff and provider community to conduct reviews that promote efficient and medically appropriate use of the member’s benefit in order to achieve cost effective and quality outcomes.
The Clinical Reviewer focuses on authorizing medically appropriate services at the right level of care. The Clinical Reviewer works primarily by telephone, and in partnership with the treating clinician or facility case manager, to ensure all required information is received in order to make a timely decision and to ensure that a coordinated discharge plan is in place. The clinical reviewer is able to effectively work independently as well as collaboratively within a highly matrixed environment. The clinical reviewer demonstrates understanding of the principles of managed care, department business objectives and measures.
- Administration of member benefits for coverage of health services in compliance with applicable regulatory and accreditation requirements
- Use of clinical tools and information / data to conduct comprehensive assessment of member eligibility and health needs
- Conduct pre-certification, concurrent, and retrospective reviews for applicable product lines and levels of care, with emphasis on utilization management, discharge planning, coordination of services, clinical outcomes, and quality of services
- Evaluation of member's clinical status, benefit plan, and appropriateness for internal and external programs and sites of service in order to facilitate determination of cost-effective, medically necessary plan of care
- Use of negotiation skills to secure appropriate services to meet identified healthcare needs
- Interaction with treatment providers, PCPs, physicians, and facilities as needed to support the plan of care
- Regular interactions with supervisors, managers, and physicians to discuss level of care questions, concerns, discharge needs, and barriers to achieving the most cost-effective, medically appropriate plan of care .
- Presentation of cases at rounds and follow-up with physicians as necessary to obtain physician input and achieve optimal outcomes
- Monitor clinical quality concerns and refer appropriately
- Identify and escalate quality of care issues through established channels
- Evaluation, monitoring, and documentation of care
- Monitor clinical care services provided to a caseload of members to optimize clinical outcomes of a given episode
- Manage caseload to optimize attainment of goals around HEDIS measures, CMS Stars, and other outcomes, quality, and accreditation metrics
- Adherence to program, departmental and organizational performance metrics including:
- Workload management
- Clinical and Quality, including audit results
- Foster clinical excellence by promoting and participating in educational opportunities
- Dealing w/ambiguity (Ability to adapt, demonstration of insight, self-direction and self-discipline)
- Flexibility/ Adaptability (Coping) (Adaptability, a calm demeanor and an understanding of the situation)
- Critical thinking / problem solving skills (ability to analyze information to construct effective solutions)
- Execution and results (ability to set goals, follow processes, meet deadlines, and deliver expected outcomes with appropriate sense of urgency)
- Communication (ability to articulate complex concepts, verbally and in writing, in decisive and focused manner)
- Builds effective relationships (ability to establish and maintain productive partnerships, internally and externally, in person and virtually, in order to facilitate professional and business goals)
- Cultural competence (demonstration of awareness, attitude, knowledge, and skills to work effectively with a culturally and demographically diverse population)
- Managed Care and health care landscape insight (demonstrates nuanced understanding of products, benefits, healthcare delivery system, accreditation and regulatory requirements, and community resources)
- Business Insight (Demonstrates an understanding of the utilization management process and its business implications, and awareness of current / future policies, practices, trends, and information affecting the business and organization)
Key technical skills :
- Focus (ability to identify and manage to key, high-leverage information, tasks, and events)
- Consistency (ability to follow identified workflows, plan requirements, clinical guidelines, and make sound, objective decisions)
- Negotiation (ability to resolve disputes and craft outcomes that address competing interests while achieving business objectives
- Call management (ability to conduct telephone conversations that ensure value in every contact, achieve the desired objectives for placing the call, and are efficient and professional)
- Clinical review (ability to evaluate the path of a given condition, the level of clinical risk, the implications for the care needed / site of service required, and the likely cost of services)
- Productivity (ability to prioritize and manage assigned workload to accomplish full slate of targeted activities)
- Management of the end to end episode of care (ability to effectively understand the described clinical condition, evaluate effectiveness of a proposed plan of care, identify the most appropriate site of service, recognize gaps in care and opportunities to coordinate services, ensure appropriate discharge planning, aftercare, and continuity, and apply differential levels of activity and involvement in cases based upon potential impact)
- Comfort and proficiency with the use of computers and technology (ability to navigate computer applications quickly and effectively, key in data proficiently in real time during phone calls, work effectively with the phone system, and quickly learn, and effectively work in, a variety of media)
- Health care professional with active Massachusetts license
- Registered Nurse (RN) with active Massachusetts license to practice. Note any restrictions against a license must be disclosed and reviewed.
- 3 years direct clinical experience preferred
- Managed care experience preferred
- Bilingual a plus
- Bachelor’s degree preferred in nursing or other allied health field, masters a plus
- Ability to work in a highly computerized environment
- This job description is not intended to be all inclusive and this role may have additional responsibilities as assigned by leader.
Time TypeFull time