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The physician reviewer is responsible for evaluating pre & post-service clinical service requests made by BCBSMA members and providers. 

The physician reviewer uses 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 Medical Director of the Physician Review Unit (PRU), the reviewer also provides clinical leadership to other areas of BCBSMA.

The Team
As an integral part of the Physician Review Unit within HMM (Health and Medical management), the physician reviewer reports to the Medical director and works with a team of actively practicing board certified physicians from a variety of specialties while collaborating with and providing clinical support across the company.

Key Responsibilities:

• Analyze available clinical documentation including peer-to-peer outreach when appropriate then apply BCBSMA criteria and guidelines to determine if coverage of a requested service is medically necessary.
• Document coverage decisions in the BCBSMA utilization management system, to clearly outline the medical decision making involved and form the basis for provider and member letters.
• Complete coverage determinations in a timely fashion to meet unit productivity guidelines and NCQA, MCRA, FEP, Medicare and other applicable regulatory and accreditation standards.
• Work as part of the PRU team, sharing ideas, communicating best practices, identifying opportunities for unit effectiveness, and creating a positive work environment.
• Actively participate in all unit quality improvement activities

Key Qualifications:

• Leadership skills, including the ability to motivate and develop staff.
• Excellent collaboration, negotiation, and written communication skills
• Ability to manage conflict effectively over the phone to maintain respectful and professional discourse.
• Effective and demonstrated oral communication and active listening skills.

Education and Experience:

• 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 necessary to process appeals.
• Experience in Utilization Management in a managed-care or risk contract environment (committee work, large group practice, or peer review)

Minimum Education Requirements:

High school degree or equivalent required unless otherwise noted above

Location

Time Type

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 and 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 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 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" Page.