Blue Cross Blue Shield of Massachusetts·Hingham, Massachusetts
Responsible for evaluating the medical necessity and appropriateness of outpatient rehabilitation services using clinical guidelines and company policies. Conducts pre-certification, concurrent, and retrospective reviews while collaborating with healthcare providers to ensure quality care.
Bring your true colors to blue.
The Role The Physical Therapy Utilization Management Reviewer is responsible for evaluating the appropriateness and medical necessity of outpatient rehabilitation services.
The position works to ensure services align with established clinical guidelines and policies.
This position is part of a larger team 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.
The Team The Physical Therapy Utilization Management Reviewer is part of a highly dedicated and motivated team of professionals.
The team includes clinicians, medical and behavioral health care managers, dietitians, pharmacists, medical directors and more, who collaborate to facilitate care.
This position is eligible for the Mobile persona with an in-office requirement to work at our Hingham location 2x/month.
Key Responsibilities: Conduct pre-certification, concurrent, 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 develop a cost-effective, medically necessary plan of care.
Successfully complete/pass the annual InterQual Interrater Reliability Test.
Interact with treating providers, PCPs, physicians, therapists, and facilities as needed to gather clinical information to support the plan of care.
Monitor clinical quality concerns and make appropriate referrals regarding concerns to the appropriate internal departments.
Understand member insurance products and benefits and apply benefits appropriately Learn and implement regulatory guidelines related to compliance and regulatory requirements (examples: NCQA, Department of Insurance).
Other duties as assigned and based on business needs.
Key Qualifications: Able to work Independently and collaboratively on a team, adaptable and flexible to change.
Ability to communicate effectively with healthcare providers and members Ability to assess clinical documentation and treatment plans, identify care gaps, and effectively communicate deficiencies to healthcare providers and members Strong critical thinking and clinical judgment skills Proficient in using electronic clinical records and computer 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 (outpatient rehabilitation inpatient acute or lower levels of care or differing clinical rehabilitation settings with transferable skills and experience.
Utilization Management experience, preferred.
Required Credentials: Doctor of Physical Therapy (DPT) degree, Master’s in Physical Therapy (MSPT) or Bachelor’s in Physical Therapy (BSPT) from a program accredited by the Commission on Accreditation in Physical Therapy Education (CAPTE).
Massachusetts state licensure required within 6 months of hire date Note: Any restrictions against a license must be disclosed and reviewed.
Minimum Education Requirements: High school degree or equivalent required unless otherwise noted above Location Hingham Time Type Full time Hourly Range: $42.18 - $51.56
The job posting range is the lowest to highest salary we in good faith believe 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 within 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 revenue-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.
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 Blue Cross Blue Shield 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 what we need for this role or possibly another one at Blue Cross Blue Shield of MA. The more voices we have represented and amplified in our business, the more we will all thrive, contribute, and be brilliant. We encourage you to bring us your true colors, , your perspectives, and your experiences. It’s in our differences that we will remain relentless in our pursuit to transform healthcare for ALL. As an employer, we are committed to investing in your development and providing the necessary resources to enable 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 join our Talent Community to stay “in the know” on all things Blue. At Blue Cross Blue Shield of Massachusetts, we believe 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.
Requires a degree in Physical Therapy (DPT, MSPT, or BSPT) from a CAPTE-accredited program and Massachusetts state licensure within 6 months. Candidates should have 3-5 years of relevant clinical experience in rehabilitation settings.
Market context
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