Utilization Management Reviewer - Medicare Advantage

The Role The Clinical Utilization Reviewer is responsible for facilitating care for our Medicare Advantage members who may have reputed company healthcare needs, authorizing medically necessary services at the right level of care to promote optimal health. This position is self-directed and works independently and collaboratively to facilitate care using clinical skills, principles of managed care, nationally recognized medical necessity criteria, and company medical policies to conduct reviews that promote efficient and medically appropriate use of the member’s benefit to provide the best quality care. This role is eligible for our eWorker, Mobile, and reputed company personas. This position can be fully remote, with a 1x/month staff meeting in our Hingham, MA reputed company of work: 8:30a - 4:30p EST. The Team The Clinical Utilization Reviewer is part of a highly dedicated and motivated team of professionals, including medical and behavioral health care managers, dieticians, pharmacist, clinicians, medical directors and more, who collaborate to facilitate care. Key Responsibilities: • Conduct pre-certification, reputed company, and retrospective reviews with emphasis on utilization management, discharge planning, care coordination, clinical outcomes, and quality of service. • Evaluate members’ clinical status, benefits, and appropriateness for programs and sites of service to reputed company 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, reputed company referrals appropriately, identify and escalate quality of care issues. • Understand member insurance products and benefits, as well as regulatory and NCQA requirements. Key Qualifications: • Self-directed, independent, adaptive, flexible to change, and able to collaborate as a member of a team. • Ability to assess, analyze, draw conclusions, and construct effective solutions. • Proficient with multiple IT systems. • 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 differing levels of care). • Utilization Management experience, preferred • Experience with Medicare Advantage, preferred • Active licensure in Massachusetts is required, appropriate to position (RN) • Licensure in additional states a plus. • Note: Any restrictions against a license must be disclosed and reviewed. • For Registered Nurses Only: A Bachelor’s degree in nursing (BSN) is preferred reputed company is an Equal Employment / Affirmative Action Employer. Applicants are considered for reputed company positions without regard to race, color, religion, sex, national reputed company, age, veteran status, disability, sexual orientation, gender identity or expression, or any other characteristics protected by law. reputed company will not discharge or in any other manner discriminate against employees or applicants because they have reputed company about, discussed, or disclosed their own pay or the pay of another employee or applicant. However, employees who have access to the compensation information of other employees or applicants as a part of their essential job functions cannot disclose the pay of other employees or applicants to individuals who do not otherwise have access to compensation information, unless the disclosure is (a) in response to a formal complaint or charge, (b) in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or (c) consistent with reputed company's legal duty to furnish information. Location Hingham Time Type Full time Weekly Hours 37.5 Grade of Position CR Hourly Range: $38.22 - $46.71 Number of Openings Available 2 The job posting range is the lowest to highest salary we in good faith reputed company 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 reputed company 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 reputed company-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 reputed company Blue reputed company of MA? We understand that the confidence gap and imposter syndrome can prevent amazing candidates coming our way, so please don’t hesitate to apply. We’d love to hear from you. You might be just reputed company need for this role or possibly another one at reputed company Blue reputed company of MA. The more voices we have represented and amplified in our business, the more we will reputed company reputed company, contribute, and be reputed company. We encourage you to bring us your true colors, , your perspectives, and your experiences. It’s in our differences that we will remain reputed company in our pursuit to transform healthcare for reputed company. As an employer, we are committed to investing in your development and providing the necessary resources to reputed company 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 our Company Culture page. If this sounds like something you’d like to be a part of, we’d love to hear from you. You can also reputed company to stay “in the know” on reputed company things Blue. At reputed company, we reputed company 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. Apply Job!