Blue Cross Blue Shield of Massachusetts
Physician Reviewer (Behavioral Health)
Blue Cross Blue Shield of Massachusetts, Boston, Massachusetts, us, 02298
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The Role The Physician Reviewer evaluates clinical service requests made by BCBSMA members and providers, using clinical judgment in conjunction with BCBSMA criteria to adjudicate requests. At the request of the Associate Medical Director of the Physician Psychologist Review Unit, the Reviewer provides clinical leadership in other areas of BCBSMA and looks 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 part‑time position works roughly 30 hours per week and is eligible for the Flex persona.
Key Responsibilities
Participate in process to evaluate clinical service requests
Practice anticipatory case management for members when 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 and Relevant Experience
MD degree with board certification in addiction psychiatry and general psychiatry or addiction medicine
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 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 MS Word
Leadership abilities and skills to motivate staff
Excellent communication and negotiation skills
Minimum Education Requirements High school degree or equivalent required unless otherwise noted above.
Location Boston, Hingham.
Time Type Part time.
Salary Range $236,970.00 - $289,630.00.
Benefits We offer a comprehensive package of paid time off, medical/dental/vision insurance, 401(k) and a suite of well‑being benefits to eligible employees.
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The Role The Physician Reviewer evaluates clinical service requests made by BCBSMA members and providers, using clinical judgment in conjunction with BCBSMA criteria to adjudicate requests. At the request of the Associate Medical Director of the Physician Psychologist Review Unit, the Reviewer provides clinical leadership in other areas of BCBSMA and looks 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 part‑time position works roughly 30 hours per week and is eligible for the Flex persona.
Key Responsibilities
Participate in process to evaluate clinical service requests
Practice anticipatory case management for members when 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 and Relevant Experience
MD degree with board certification in addiction psychiatry and general psychiatry or addiction medicine
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 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 MS Word
Leadership abilities and skills to motivate staff
Excellent communication and negotiation skills
Minimum Education Requirements High school degree or equivalent required unless otherwise noted above.
Location Boston, Hingham.
Time Type Part time.
Salary Range $236,970.00 - $289,630.00.
Benefits We offer a comprehensive package of paid time off, medical/dental/vision insurance, 401(k) and a suite of well‑being benefits to eligible employees.
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