Remote Utilization Management Jobs in Boston, MA

The Role

The Role The Clinical Care Manager is responsible for facilitating care for members and families of members who may have rising health risks or complex healthcare needs, to promote optimal health.

This position is self-directed and works independently and collaboratively to facilitate care based on the principles of care management. Facilitation is focused on assessing needs, identifying health care disparities, social determinants of health, and any barriers to care.

The Team

The Team The Clinical Care Manager is part of a highly dedicated and motivated team of professionals, including medical and behavioral health care managers, dieticians, pharmacist, clinicians, medical directors and more, who collaborate to facilitate care.

Key Responsibilities:

* Engage members in appropriate plans of care, coordinate care and services as appropriate, communicate effectively and provide members with education and resources as needed.Promote member compliance with treatment plan, encourage shared decision-making, and set appropriate goals to promote optimal member outcomes.

* Interpret and apply case management criteria, processes, policies, and regulatory standards to create, follow and appropriately document comprehensive care management plans.

* Review medication list and educate members with complex pharmacy needs, and counsel on side effects and mitigation strategies for specific treatment protocols.

* Successfully connect, engage, and maintain member engagement to support seamless care transitions and optimized health outcomes.

* Interact with treatment providers, PCPs, physicians, therapists, and facilities as needed to gather clinical information to support the plan of care.

* Monitor clinical quality concerns, make referrals appropriately, identify and escalate quality of care issues.

* Understand member insurance products and benefits, as well as regulatory and NCQA requirements.

Key Qualifications:

* Ability to identify and document member-driven, specific, measurable activities that address actionable behaviors and goals

* Self-directed, independent, adaptive, flexible to change, and able to collaborate as a member of a team.

* Proficient with multiple IT systems.

* Demonstration of awareness, attitude, knowledge, and skills needed to work effectively with a culturally and demographically diverse population.

Education and Experience:

* 3-5 years relevant experience in a variety of appropriate clinical health care settings (Inpatient, outpatient, or differing levels of care).

* Utilization Management experience, preferred

* Active licensure in Massachusetts is required, appropriate to position (RN/PT)

o Licensure in additional states a plus.

o Note: Any restrictions against a license must be disclosed and reviewed.

#LI-REMOTE

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.