Physician Reviewer (Physician Review Unit)

About the position Ready to help us transform healthcare? Bring your true colors to blue. The Role The Physician Reviewer is responsible for evaluating pre & post-service clinical service requests made by BCBSMA members and providers. The Physician Reviewer uses their clinical judgment in conjunction with BCBSMA criteria to adjudicate these requests, engaging in peer-to-peer outreach with treating providers, as appropriate. At the request of the Senior Medical Director of the Physician Review Unit (PRU), the reviewer also provides clinical leadership in other areas of BCBSMA. The physician reviewer will exercise sound clinical judgment in looking for opportunities to manage and optimize members’ clinical situations and health outcomes, with a view toward creative problem solving and in anticipation of possible future clinical problems for the member. This position is eligible for the Flex persona.

Responsibilities

• Apply BCBS Criteria and guidelines to case reviews of BCBS members in order to determine if coverage of the requested service is appropriate, as determined by plan benefit design, plan riders, and medical necessity criteria.
• In making coverage decisions regarding level of care, benefit and medical policy, evaluate individual case information received from members, ordering and treating providers, case managers, and office staff
• Assess available clinical documentation and identify clinically relevant missing information upon which a coverage determination depends, making reasonable efforts to obtain relevant information via UM clinical reviewers, peer-to-peer outreach, and/or direct provider EMR access, as available
• Document critical activities relating to coverage decisions and final determinations regarding coverage in the BCBSMA utilization management system (MHK), so that decisions and medical reasoning related to the decision are clear and useful to PRU customers (members, consumers, providers, case managers, brokers, and other users of MHK)
• Complete coverage determinations in a timely fashion in order to meet regulatory, accreditation, and unit productivity guidelines
• Work as part of the PRU team, sharing ideas, communicating best practices, identifying opportunities for unit effectiveness, and creating a positive work environment
• Develop and continuously improve expertise and understanding of BCBS medical policy, products, computer systems, PRU operating policies, and Health and Medical Management policies
• Practice anticipatory case management for members whose cases come for review, identifying opportunities for improved care coordination and placing internal BCBSMA case management referrals, as clinically appropriate
• Participate in the PRU’s appeal process of service and claims denials
• Participate in the development of PRU’s policies and procedures
• Actively participate in all unit continuous quality improvement activities
• Perform additional tasks as assigned by the leadership of the PRU
• Adhere to NCQA, URAC, MCRA, FEP, Medicare and other applicable regulatory and accreditation standards

Requirements

• MD or DO degree with an active specialty board certification
• Current and valid, unrestricted license to practice medicine in the state of Massachusetts
• Active clinical practice in order to process appeals
• Experience in Utilization Management in a managed-care or risk contract environment (committee work, large group practice, or peer review)
• Experience with basic computer programs, including but not limited to Windows OS, MS Word and MS Outlook
• Leadership abilities, including skills to motivate and develop staff
• Excellent collaboration, negotiation, and verbal/written communication skills
• Ability to manage conflict effectively over the phone with a demonstrated ability to establish a professional environment conducive to maintaining psychological safety and respectful discourse
• Effective provider and case management communication skills, with demonstrated active listening skills
• Able to adequately perform all responsibilities of the role in a mixed in-person/virtual (“Mobile” or “eWorker”) work setting

Benefits

• paid time off
• medical/dental/vision insurance
• 401(k)
• a suite of well-being benefits

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