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The Role The Clinical Utilization Reviewer is responsible for facilitating care for members who may have complex 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.
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 and concurrent and retrospective clinical review of in-state and out-of-state inpatient cases at acute residential treatment programs and partial hospitalization through the application of evidence-based medical necessity criteria and BCBSMA policies and procedures Focus on efficient utilization management with emphasis on discharge planning Understand and appropriately manages member's benefits to maximize health care quality Collaborate with physician reviewers, case managers, project leaders and associates within BCBSMA to optimize member care and ensure a constructive provider experience Facilitate 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 Collaborate with members/families, providers, medical staff and/or other members of the treatment team to coordinate and support health action plans developed by providers that include treatment goals, interventions, and expected clinical outcomes and that support quality and medical management goals and objectives Educate and support members/families regarding benefits, eligibility, BCBSMA policies and processes with the goal to empower self-advocacy Identify and refer members who may benefit from high-risk case management and disease state management intervention Maintain 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 Utilize 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 Exhibit customer satisfaction orientation in every aspect of carrying out responsibilities Meet or exceed annual performance goal of 90% cumulatively for case audits and recorded call audits, where applicable.
