RN Utilization Management Reviewer

Job Overview

The Clinical Utilization Reviewer is responsible for facilitating care for members with complex healthcare needs by authorizing medically necessary services at the appropriate level of care to promote optimal health. The role is self‑directed, working independently and collaboratively with a multidisciplinary team of professionals.

• Conduct pre‑certification, concurrent, and retrospective reviews focusing on utilization management, discharge planning, care coordination, clinical outcomes, and quality of service.
• Evaluate members’ clinical status, benefits, and appropriateness for programs and sites of service to develop a cost‑effective, medically necessary plan of care.
• Pass the annual Inter Qual Interrater Reliability Test.
• Interact with treatment providers, PCPs, physicians, therapists, and facilities to gather clinical information and support the plan of care.
• Monitor clinical quality concerns, make referrals appropriately, and identify and elevate quality of care issues.
• Understand member insurance products and benefits, regulatory requirements, and NCQA standards.

• Self‑directed, independent, adaptive, and flexible to change; able to collaborate as part of a team.
• Strong analytical skills with the ability to assess, draw conclusions, and construct effective solutions.
• Proficient with multiple IT systems.
• Demonstrated awareness, attitude, knowledge, and skills necessary to work effectively with a culturally and demographically diverse population.
• 3–5 years of relevant experience in clinical healthcare settings (inpatient, outpatient, or other levels of care).
• Utilization Management experience preferred.
• Active licensure in Massachusetts is required (RN). Licensure in additional states is a plus.
• A Bachelor’s degree in nursing (BSN) is preferred; minimum education requirement is a high school diploma or equivalent.

Hourly Rate: $39.32 – $48.06. This role may also be eligible for variable pay. Benefits include paid time off, medical/dental/vision insurance, 401(k), and a suite of well‑being benefits for eligible employees.

Hingham, Massachusetts

Blue Cross Blue Shield of Massachusetts is an Equal Employment Employer and provides an equal opportunity to all applicants and employees without regard to race, color, religion, sex, national origin, age, veteran status, disability, sexual orientation, gender identity or expression, or any other characteristics protected by law. The company will not discriminate against employees or applicants because they have inquired about or disclosed compensation information.