Job Information
Blue Cross Blue Shield of Massachusetts Physician Reviewer BH PRU in Boston, Massachusetts
Ready to help us transform healthcare? Bring your true colors to blue.
The Physician Reviewer is responsible for evaluating clinical service requests made by BCBSMA members and providers. The Physician Reviewer uses his/her clinical judgment in conjunction with BCBSMA criteria to adjudicate these requests. At the request of the Associate Medical Director of the Physician Psychologist Review Unit, the Reviewer also provides clinical leadership in other areas of BCBSMA. The Physician Reviewer will look for opportunities to manage members’ clinical situations with a view toward creative problem solving and anticipation of possible future clinical problems for the member.
This position is eligible for the Flex persona.
Responsibilities:
Participate in process to evaluate clinical service requests
Practice anticipatory case management for members whose cases come for review, in partnership with case managers
Participate in Physician Psychologist Review Units’ appeal process of service denials
Participate in development of Physician Psychologist Review Units’ policies and procedures
Actively participate in all unit continuous quality improvement activities
Perform additional tasks as assigned by the Associate Medical Director of the Physician Psychologist Review Unit
Adhere to NCQA, URAC, Medicare and other regulatory standards
Education/Relevant Experience:
MD degree with board certification in general psychiatry and child psychiatry
Unrestricted current and valid license to practice medicine in the state of Massachusetts and/or in any other relevant/applicable state
Incumbent must be a BCBSMA credentialed provider
Active clinical practice in order to participate in panel appeals
Experience in Utilization Management in a managed-care environment (as a clinician or in committee work, large group practice, or peer review)
Experience with basic computer programs, including but not limited to MS Word
Leadership abilities, including skills to motivate staff
Excellent communication and negotiation skills
#LI-REMOTE
Minimum Education Requirements:
High school degree or equivalent required unless otherwise noted above
LocationBoston, HinghamTime TypePart time
Salary Range: $232,300.00 - $284,130.00
The job posting range is the lowest to highest salary we in good faith believe we would pay for this role at the time of this posting. We may ultimately pay more or less than the posted range, and the range may be modified in the future. An employee’s pay position within the salary range will be based on several factors including, but limited to, relevant education, qualifications, certifications, experience, skills, performance, shift, travel requirements, sales or revenue-based metrics, and business or organizational needs and affordability.
This job is also eligible for variable pay.
We offer comprehensive package of benefits including paid time off, medical/dental/vision insurance, 401(k), and a suite of well-being benefits to eligible employees.
Note: No amount of pay is considered to be wages or compensation until such amount is earned, vested, and determinable. The amount and availability of any bonus, commission, or any other form of compensation that are allocable to a particular employee remains in the Company's sole discretion unless and until paid and may be modified at the Company’s sole discretion, consistent with the law.
WHY Blue Cross Blue Shield of MA?
We understand that the confidence gap (https://www.theatlantic.com/magazine/archive/2014/05/the-confidence-gap/359815/) and imposter syndrome (https://www.braintreepayments.com/blog/overcoming-imposter-syndrome/) can prevent amazing candidates coming our way, so please don’t hesitate to apply. We’d love to hear from you. You might be just what we need for this role or possibly another one at Blue Cross Blue Shield of MA. The more voices we have represented and amplified in our business, the more we will all thrive, contribute, and be brilliant. We encourage you to bring us your true colors, , your perspectives, and your experiences. It’s in our differences that we will remain relentless in our pursuit to transform healthcare for ALL.
As an employer, we are committed to investing in your development and providing the necessary resources to enable your success. Learn how we are dedicated to creating an inclusive and rewarding workplace that promotes excellence and provides opportunities for employees to forge their unique career path by visiting our Company Culture (https://careers.bluecrossma.org/us/en/culturepage) page. If this sounds like something you’d like to be a part of, we’d love to hear from you. You can also join our Talent Community (https://careers.bluecrossma.org/us/en/jointalentcommunity?applyType=JTC) to stay “in the know” on all things Blue.
At Blue Cross Blue Shield of Massachusetts, we believe in wellness and that work/life balance is a key part of associate wellbeing. For more information on how we work and support that work/life balance visit our "How We Work (https://careers.bluecrossma.org/us/en/how-we-work) " Page.
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.