MSK Clinical Utilization Reviewer, LPN

The Role
The MSK Clinical Utilization Reviewer - LPN is responsible for reviews of commercial members with musculoskeletal healthcare needs, authorizing medically necessary and level of care assessments to promote a comprehensive and balanced approach to musculoskeletal services to mitigate trend and drive value for our members.

Reporting to the associate director of the MSK program, the LPN will work collaboratively with the MSK team and entire Clinical Utilization management team to facilitate orthopedic care using clinical skills, principles of managed care, nationally recognized medical necessity criteria, and company medical policies to conduct reviews that promote efficient and medically appropriate use of the member's benefit to provide the best quality care.

This role is eligible for our eWorker, Mobile, and Resident personas. This position can be fully remote, with a 1x/month staff meeting in our Hingham, MA office - local candidates preferred. Hours of work: 8:30a - 4:30p EST.

The Team
The MSK Clinical Utilization Reviewer - LPN is part of a highly dedicated and motivated team of MSK Utilization Reviewers including LPNs, RNs, and PTs. Within the health and medical management (HMM) division of the company, health professionals include medical and behavioral health RNs, LPNs, PTs, OTs, LICSWs , LMHC care managers, dieticians, pharmacist, clinicians, medical directors and more, who collaborate to facilitate care.

Key Responsibilities:

• Conduct pre-certification and retrospective reviews with emphasis on utilization management, discharge planning, care coordination, clinical outcomes, and quality of service by applying industry standard criteria (Interqual criteria used) and BCBSMA medical policies for defined inpatient or service requests.
• Evaluate members' clinical status, benefits, and appropriateness for programs and sites of service to develop a cost-effective, medically necessary plan of care.
• Pass annual InterQual Interrater Reliability Test.
• Communicate openly and professionally with requesting healthcare providers and facilities as needed to gather clinical information to support the plan of care and perform the MSK review.
• Monitor clinical quality concerns, make Care Management referrals appropriately, identify and escalate quality of care issues, specifically related to outlier cases, long LOS cases or complicated prior authorization requests.
• Understand member insurance products and benefits, as well as regulatory and NCQA requirements.
• Escalate reviews to seasoned RN or PT MSK Clinical Utilization reviewers and/or associate director for more complex case questions as appropriate.
• Appropriately refer requests to Physician Review Unit (PRU) for potential denial of prior authorization requests with complete data and documentation to support reason for PRU referral.
• Collaborate within a team of professionals both internally and externally to provide members and providers with a high level of benefits education and BCBSMA medical policy requirements related to prior authorization requirements.
• Support a positive workplace environment, collaborate, and share clinical knowledge and skills to support our culturally and demographically diverse member population.
• Other clinical duties as assigned.

Key Qualifications:

• Self-directed, independent, adaptive, flexible to change, and able to collaborate as a member of a team.
• Ability to efficiently and accurately assess clinical documentation, analyze, draw conclusions, and construct effective recommendations for authorization or care management services.
• Proficient with multiple IT systems, demonstrates strong digital skills based on prior roles.
• Demonstration of awareness, attitude, knowledge and skills needed to work effectively with a culturally and demographically diverse population.

Education and Experience:

• 3-5 years of relevant clinical healthcare experience (orthopedic and/or pain management experience preferred).
• Utilization Management experience preferred
• Active licensure in Massachusetts is required, appropriate to position - LPN
  • Licensure in additional states a plus.
  • Note: Any restrictions against a license must be disclosed and reviewed.

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.