Clinical Reviewer

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

Preferred Qualifications:

• 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).

The pay range for this position takes into account a wide range of factors including, but not limited to, specific competencies, relevant education, qualifications, certifications, relevant experience, skills, seniority, performance, travel requirements, internal equity, business or organizational needs, and alignment with market data. At Blue Cross of Idaho, it is not typical for an individual to be hired at or near the top range for the position. Compensation decisions are dependent on factors and circumstances at the time of offer.

We offer a robust package of benefits including paid time off, paid holidays, community service and self-care days, medical/dental/vision/pharmacy insurance, 401(k) matching and non-contributory plan, life insurance, short and long term disability, education reimbursement, employee assistance plan (EAP), adoption assistance program and paid family leave program.

We will adhere to all relevant state and local laws concerning employee leave benefits, in line with our plans and policies.

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.