Physician Reviewer

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 HinghamTime Type Full time Salary Range: $230,850.00 - $282,150.00 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.