Clinical Reviewer

Requirements

• BSN
• MSW
• What a day of a Clinical Reviewer would look like:
• Make clinical decisions for Behavioral Health and/or Medical requests using approved and accepted plan policies and criteria.
• Determine eligibility and benefit coverage according to member and provider contracts.
• Identify appropriate members for medical or behavioral health case management.
• Respond to requests for authorization of Behavioral Health and/or Medical services and inpatient procedures.
• Document and report potential quality of care or service issues to leadership.
• Perform review of business workflows to ensure consistent application.
• May provide review according to established criteria for procedural authorization.
• Perform other duties and responsibilities as assigned.
• Additional skills that we are looking for:
• High degree verbal and written communication
• Independent and critical thinking
• Handle multiple projects simultaneously
• Work well in a team environment
• As of the date of this posting, a good faith estimate of the current pay range is $73,321 - $102,650. The position is eligible for an annual incentive bonus (variable depending on company and employee performance).
• We will adhere to all relevant state and local laws concerning employee leave benefits, in line with our plans and policies.
• Reasonable accommodations

Benefits

Additional Information

Blue Cross of Idaho is seeking a Clinical Reviewer to support the Healthcare Operations initiatives to ensure the delivery of medically necessary and appropriate, cost-effective and timely, quality health care services, through the focused procedural review and authorization process. Location: this position has preference to be based in Meridian Idaho and offers hybrid work location; potential consideration for working fully remote within a mutually acceptable location. #LI-Remote; #LI-Hybrid. We're looking for a Clinical Reviewer with: Experience: 3 years' relevant experience Education: Associates Degree in Nursing or Bachelor's Degree in Social Work; or equivalent work experience (Two years' relevant work experience is equivalent to one-year college) Licenses/Certifications: Must hold one of the following: Valid unrestricted Idaho Registered Nursing License Valid unrestricted Idaho Social Worker License

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