Utilization Management Reviewer Job at Blue Cross Blue Shield of Michigan, United States

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  • Blue Cross Blue Shield of Michigan
  • United States

Job Description

Utilization Management Reviewer

Our Utilization Management Reviewers evaluate medical necessity for inpatient and outpatient services, ensuring treatment aligns with clinical guidelines, regulatory requirements, and patient needs. This role requires reviewing provider requests, gathering necessary medical documentation, and making determinations based on clinical criteria. Using professional judgment, the Clinical Care Reviewer assesses the appropriateness of services, identifies care coordination opportunities, and ensures compliance with medical policies. When necessary, cases are escalated to the Medical Director for further review. The reviewer independently applies medical and behavioral health guidelines to authorize services, ensuring they meet the patient's needs in the least restrictive and most effective manner. The Utilization Management Reviewer must maintain a strong working knowledge of federal, state, and organizational regulations and consistently apply them in decision-making. Productivity expectations include meeting established turnaround times, quality benchmarks, and efficiency metrics in a fast-paced environment.

Remote role

Monday through Friday, 8:00 AM to 5:00 PM

4 recognized company holidays to include Thanksgiving and Christmas (rotating)

Weekends based on business needs

Conduct utilization management reviews by assessing medical necessity, appropriateness of care, and adherence to clinical guidelines

Collaborate with healthcare providers to facilitate timely authorizations and optimize patient care

Analyze medical records and clinical data to ensure compliance with regulatory and payer guidelines

Communicate determinations effectively, providing clear, evidence-based rationales for approval or denial decisions

Identify and escalate complex cases requiring physician review or additional intervention

Ensure compliance with Medicaid industry standards

Maintain productivity and efficiency by meeting established performance metrics, turnaround times, and quality standards in a high-volume environment

Associate's Degree in Nursing (ASN) required; Bachelor's Degree in Nursing (BSN) preferred

Minimum of 3 years of diverse clinical experience as a Registered Nurse in an Intensive Care Unit (ICU), Emergency Department (ED), Medical-Surgical (Med-Surg), Skilled Nursing Facility (SNF), Rehabilitation, or Long-Term Acute Care (LTAC), home health care, or medical office setting

Minimum of 2 years of experience applying evidence-based criteria (e.g. InterQual) to complete prior authorization and concurrent reviews for inpatient and/or outpatient services

Experience conducting utilization management reviews for a payor (e.g. Medicaid, Medicare or commercial plan) preferred

Active and unencumbered NLC required

Proficiency using Electronic Medical Record Systems to efficiently document and assess patient cases

Strong understanding of utilization review processes, including medical necessity criteria, care coordination, and regulatory compliance

Working knowledge of InterQual criteria

Demonstrated ability to meet productivity standards in a fast-paced, high-volume utilization review environment

Proficiency using MS Office to include Excel, Word, Outlook, and Teams

Ability to type with speed and accuracy

Flexible work solutions include remote options, hybrid work schedules, competitive pay, paid time off, holidays and volunteer events, health insurance coverage for you and your dependents on Day 1, 401(k) tuition reimbursement, and more.

Job Tags

Remote work, Monday to Friday, Flexible hours, Weekend work

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