Clinical Reviewer
Bcidaho

Job Info

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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.

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

What a day of a Clinical Reviewer would look like:

• Make clinical decisions 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 medications or inpatient procedures and services.
• Document and reports potential quality of care or service issues to leadership.
• Perform peer to peer audits to assist with consistency of application of business workflows.
• 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

Reasonable accommodations

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed above are representative of the knowledge, skill and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

We are an Equal Opportunity Employer and do not discriminate against any employee or applicant for employment because of race, color, sex, age, national origin, religion, sexual orientation, gender identity, status as a veteran, and basis of disability or any other federal, state or local protected class.

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