Medicare Advantage- Nurse Reviewer (UM)

Today's healthcare industry -- dynamic and changing at a fast pace. Recruiting talented people can mean the difference between success or failure. At Blue Cross and Blue Shield of Massachusetts, our record of achievement represents a history of hiring the best people we can find, and then challenging them to excel. It's the kind of environment that enables us to give our best to the consumers we serve, and at the same time, work to the potential of those who work for us. Blue Cross Blue Shield of Massachusetts is an Equal Opportunity Employer/Affirmative Action Employer. Applicants are considered for all positions without regard to race, color, religion, sex, national origin, age, veteran status, disability, sexual orientation, or any other characteristics protected by law.Responsibilities Pre-certification, concurrent and retrospective clinical review of in state and out of state inpatient cases at acute, rehabilitation and skilled nursing facilities; pre-certification, concurrent, and retrospective clinical review of outpatient ambulance, non participating specialist, and homecare cases. Focus on utilization management with emphasis on discharge planning. Some case management components may be required. Manage member's benefits to maximize health care dollars. Apply Medicare guidelines in determination of medical appropriateness. Utilize InterQual guidelines as a screening tool for review of acute rehabilitation and skilled nursing facility requests. Work in conjunction with physician reviewers and other departments within BCBSMA. Facilitate through communication between members/families, providers, medical staff and/or others with information relating to benefits and the utilization management process. Collaborate with members/families, providers, medical staff and/or others in order to develop, implement/authorize, and document treatment plans that include treatment goals, interventions, and expected clinical outcomes. Educate and support members/families regarding benefits, eligibility, BCBSMA policies and processes with the goal to empower self-advocacy. Utilize the computer systems to 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. Other responsibilities as assigned by management.Qualifications Excellent organizational skills. Strong problem-solving ability under pressure. Excellent communication skills a must. Proven customer service skills. Basic to intermediate ease of use with computer keyboard with a working understanding of common computer software such as Microsoft Word, Excel and Outlook. Ability to work as part of a team, but also function independently. Knowledge of Medicare guidelines. Yearly certification in InterQual required. Registered nurse with an active professional Massachusetts license. 3-5 years of clinical experience in medical/surgical and acute care settings and geriatrics Bachelor's Degree in Nursing or health-related field preferred Utilization Management preferred Medicare and Case management experience desirable CCM, CPUR or CPUM desirable Position Information Location:  Quincy, MA 02171 Job Category:  Medical/Health Reference Code:  bcbs-00001475 Our commitment to building a diverse workplace is without question. We are an Equal Opportunity Employer.