Physician Reviewer BH PRU

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

High school degree or equivalent required unless otherwise noted above

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 theconfidence gapandimposter syndromecan 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 ourCompany Culturepage. If this sounds like something you'd like to be a part of, we'd love to hear from you. You can also join ourTalent Communityto 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" Page.