Blue Cross Blue Shield of Massachusetts Clinical Reviewer (RN Required) in Quincy, Massachusetts

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Major Responsibilities:

  • Facilitate day-to-day technical functions of unit including effective delegation of work assignments.

  • Act as primary point of contact for associates in resolving inquiries

  • Optimize levels of service to internal and external customers to enhance overall member and provider satisfaction

  • Communicate key information to leadership on day-to-day team activities and suggest process improvements

  • Improve operating efficiencies while maximizing provider, member and associate satisfaction

  • Coach and counsel associates offering guidance on workflows, complex issues and recent communication/action steps

  • Make decisions, in consultation with Business Leader, to ensure timely resolution of provider issues and problems

  • Disseminate benefit and program changes and information in organized and timely fashion

  • Assist in implementation of and adherence to corporate, division and team policies and procedures

  • Support team through ongoing monitoring and delegating of unit tasks and responsibilities

  • Contribute to performance planning and associate Performance reviews

  • Perform quality reviews, on a regularly scheduled basis, of cases and recorded calls, where applicable.

  • Meet or exceed annual performance goal of 90% cumulatively for case audits and recorded call audits, where applicable.

  • Coach and mentor associates to improve the quality and accuracy of case management plan of care

  • Establish and maintain positive relationships and effective communication with internal and external customers

  • Foster a team-based environment by participating in various activities that lead to associate support and member and provider satisfaction

  • Assume other duties/ projects as assigned by management

  • Maintain an active case load

  • Other responsibilities as assigned by management

Qualifications (Knowledge, skills and abilities):

  • Thorough knowledge of MCPS

  • Solid clinical knowledge in general medical/surgical arena; specialty knowledge a plus

  • Excellent organizational skills, ability to manage multiple ongoing tasks and meet strict deadlines in a fast-paced environment

  • 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; work with providers and members to ensure satisfaction of interaction despite unexpected/ undesired outcomes

  • Basic to intermediate computer proficiency and working understanding of common computer software such as Microsoft Word, Excel and Outlook

  • Ability to integrate as part of working team and function independently to complete assigned workload

  • Demonstrate effective listening, time management, organizational and interpersonal skills

  • Achieve a passing score on the yearly InterQual interrater reliability test

Education/Relevant Experience

  • Registered clinician 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

#LI-DNI

LocationQuincyTime TypeFull time

Voted as the highest in member satisfaction among Massachusetts commercial health plans by JD Power, Blue Cross Blue Shield of Massachusetts is a community-focused, tax-paying, not-for-profit health plan headquartered in Boston. We have been a market leader for over 75 years, and are consistently ranked among the nation's best health plans. Our daily efforts are dedicated to effectively serving our 2.8 million members, and consistently offering security, stability, and peace of mind to both our members and associates.

Our Commitment to You

We are committed to investing in your development and providing the necessary resources to enable your success. We are dedicated to creating a refreshing and rewarding workplace that promotes excellence and provides opportunities for employees to forge their unique career path. We take pride in our diverse, community-centric, wellness-focused culture and believe every member of our team deserves to enjoy a positive work-life balance.

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

Blue Cross Blue Shield of Massachusetts will not discharge or in any other manner discriminate against employees or applicants because they have inquired 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 Blue Cross Blue Shield of Massachusetts's legal duty to furnish information.