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