Physician Reviewer; Behavioral Health

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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.

• 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

• 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

High school degree or equivalent required unless otherwise noted above.

Boston, Hingham.

Part time.

$ - $.

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.