Qureos Mentor

Blue Cross Blue Shield of Massachusetts

Ready to help us transform healthcare? Bring your true colors to blue.
 The Role
 The Clinical Utilization Reviewer is responsible for facilitating care for members who may have complex healthcare needs, authorizing medically necessary services at the right level of care to promote optimal health.
 This position is self-directed and works independently and collaboratively to facilitate care using clinical skills, principles of managed care, nationally-recognized medical necessity criteria, and company medical policies to conduct reviews that promote efficient and medically appropriate use of the member’s benefit to provide the best quality care.
 
The Team
 The Clinical Utilization Reviewer 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.
 
This position is eligible for our eWorker, Mobile, and Resident personas. This position can be fully remote, with the expectation to work in our Hingham office 1x month.
 
Key Responsibilities: 
Conduct pre-certification, concurrent, and retrospective reviews with emphasis 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 annual InterQual Interrater Reliability Test.
 
Collaborate with a team of professionals, including clinical utilization managers, account representatives, member service associates, dietitians, and physicians, to provide members with a high level of care coordination.
 
Interact with treatment providers, PCPs, physicians, therapists, and facilities needed to gather clinical information to support the plan of care.
 
Support members on their family building journey by reviewing medical policies, benefits and authorization determinations.
 
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.
 
Identify cases to be presented at medical rounds and follow up with providers on recommendations to achieve optimal outcomes for members.
 
Support a positive workplace environment, collaborate, and share clinical knowledge and skills to support our culturally and demographically diverse member population.
 
Other clinical duties as assigned.
 
Key Qualifications: 
Self-directed, independent, adaptive, flexible to change, and able to collaborate as a member of a team.
 
Ability to assess, analyze, draw conclusions, and construct effective solutions.
 
Excellent written and verbal communication skills.
 
Proficient with multiple IT systems.
 
Able to identify and set goals, follow processes, meet deadlines, and deliver expected outcomes with the appropriate sense of urgency.
 
Ability to interpret, evaluate, and document complex medical information to identify and communicate relevant and actionable conditions, circumstances, and behaviors.
 
Demonstration of awareness, attitude, knowledge, and skills needed to work effectively with a culturally and demographically diverse population.
 
Willingness to learn new business and clinical skills.
 
Education and Experience: 
3-5 years relevant experience in a variety of appropriate clinical health care settings (Inpatient, outpatient, or differing levels of care).
 
Experience with IVF, maternity, reproductive and gender affirming health, preferred.
 
2-3 years of Utilization Management experience.
 
Active licensure in Massachusetts is required, appropriate to position (RN)
 
Licensure in additional states a plus.
 
Note: Any restrictions against a license must be disclosed and reviewed.
 
For Registered Nurses Only: A bachelor’s degree in nursing (BSN) is preferred.
 
#LI-Hybrid
 
Minimum Education Requirements: 
High school degree or equivalent required unless otherwise noted above
 
Location Hingham Time Type Full time
 
Hourly Range: $39.32 - $48.06
 
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 the confidence gap and imposter syndrome can 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 our Company Culture page. If this sounds like something you’d like to be a part of, we’d love to hear from you. You can also join our Talent Community to 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.

RN Utilization Management Reviewer

Ready to help us transform healthcare? Bring your true colors to blue.
 The Role
 The Physical Therapy Utilization Management Reviewer is responsible for evaluating the appropriateness and medical necessity of outpatient rehabilitation and other services within scope of practice per business needs. The reviewer will ensure services align with established clinical guidelines and policies.
 This position is part of a larger team and works independently and collaboratively to facilitate care using clinical skills, principles of managed care, nationally recognized medical necessity criteria, and company medical policies to conduct reviews that promote efficient and medically appropriate use of the member’s benefit to provide the best quality care.
 
The Team
 The commercial Physical Therapy Utilization Management Reviewer is part of a highly dedicated and motivated team of professionals. The team includes clinicians, medical and behavioral health care managers, dietitians, pharmacists, medical directors and more, who collaborate to facilitate care.
 
This position is eligible for the Mobile persona with an in-office requirement to work at our Hingham location 2x/month.
 
Key Responsibilities: 
Conduct pre-certification, concurrent, and retrospective reviews with emphasis 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.
 Successfully complete/pass the annual InterQual Interrater Reliability Test.
 Interact with treating providers, PCPs, physicians, therapists, and facilities as needed to gather clinical information to support the plan of care.
 Monitor clinical quality concerns and make appropriate referrals regarding concerns to the appropriate internal departments.
 Understand member insurance products and benefits and apply benefits appropriately
 Learn and implement regulatory guidelines related to compliance and regulatory requirements (examples: NCQA, Department of Insurance).
 Other duties as assigned and based on business needs.
 
Key Qualifications: 
Able to work Independently and collaboratively on a team, adaptable and flexible to change.
 Ability to communicate effectively.
 Ability to manage ambiguity and assess, analyze, and determine next steps.
 Critical thinking and clinical judgment.
 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 (outpatient rehabilitation inpatient acute or lower levels of care or differing clinical rehabilitation settings with transferable skills and experience.
 Utilization Management experience, preferred.
 Active licensure in Massachusetts is required, appropriate to position (PT).
 Licensure in additional states a plus.
 Note: Any restrictions against a license must be disclosed and reviewed.
 Credentials: Doctor of Physical Therapy (DPT) degree, Master’s in Physical Therapy (MSPT) or Bachelor’s in Physical Therapy (BSPT) from a program accredited by the Commission on Accreditation in Physical Therapy Education (CAPTE).
 
Minimum Education Requirements: 
High school degree or equivalent required unless otherwise noted above
 
Location Hingham Time Type Full time
 
Hourly Range: $42.18 - $51.56
 
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 the confidence gap and imposter syndrome can 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 our Company Culture page. If this sounds like something you’d like to be a part of, we’d love to hear from you. You can also join our Talent Community to 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.

PT Utilization Management Reviewer

Ready to help us transform healthcare? Bring your true colors to blue.
 
What we need: 
We are seeking a highly experienced and results-driven experience Salesforce Business Analyst to work closely with subject matter experts, end users and development teams to ensure alignment and the successful implementation of business solutions, with a strong focus on Salesforce and process optimization. This role is critical in analyzing complex business needs, defining scope, designing solutions, and driving continuous improvement across commercial operations.
 
This position is eligible for the Flex persona.
 
Your Day to Day: 
Process Analysis & Optimization
 Analyze existing business processes, Salesforce flows, and workflows to identify inefficiencies and opportunities for improvement.
 Conduct end-to-end process analysis, including mapping “as-is” and “to-be” states using industry-standard frameworks.
 Identify and resolve bottlenecks and streamline operations to enhance performance and reduce costs.
 Analyze and document a business process to elicit requirements and engage stakeholders to visualize a future state.
 
Stakeholder Engagement & Requirements Management
 Collaborate with cross-functional teams, stakeholders, and end users to gather, document, and validate business requirements.
 Serve as a liaison between business and technical teams, ensuring alignment and understanding across all levels.
 Manage stakeholder expectations, resolve conflicts, and facilitate consensus on business needs and priorities.
 
Solution Design & Implementation
 Translate business requirements into effective technical and process solutions, including automation and Salesforce configurations.
 Lead solution design initiatives that align with strategic goals and support operational excellence.
 Partner with development teams during implementation to ensure solutions are effectively delivered and meet business objectives.
 Support and validate project delivery to ensure the solution meets the requirements.
 
Data Analysis & Reporting
 Perform data analysis to identify trends, uncover insights, and support decision-making.
 Create dashboards and reports to monitor key performance indicators (KPIs) and track the success of implemented solutions.
 
Project Management & Change Enablement
 Lead and support work and projects focused on Salesforce enhancements and business process reengineering.
 Support change management activities, including impact analysis, training, and communication plans to ensure user adoption and operational readiness.
 
Testing & Documentation
 Facilitate user acceptance testing (UAT), validate configurations, and troubleshoot issues post-implementation.
 Develop clear, concise documentation including business requirements, process flows, user stories, training guides, and release notes.
 
Knowledge Sharing & Continuous Learning
 Stay current on industry trends, Salesforce platform updates, and best practices in business analysis and process improvement.
 Mentor peers and support end-user training initiatives to foster organizational knowledge and system proficiency.
 
We're Looking for: 
Strong knowledge of business operations, sales workflows, and end-to-end commercial processes
 Proven experience in Agile methodologies and complex project delivery
 Proficient in process improvement tools (e.g., Microsoft Visio), data analysis tools, and BA toolkits.
 Strong documentation, communication, and presentation skills
 Effective problem-solving, critical thinking, and decision-making capabilities
 Ability to manage multiple projects, work independently, and collaborate across diverse teams
 Skilled in change management, stakeholder engagement, conflict resolution, and training delivery
 
What You Bring: 
10+ years of business analysis experience
 10+ years of hands-on Salesforce experience
 7+ years Agile delivery experience
 Salesforce Business Analyst Certification preferred
 IIBA certification required (ECBA, CCBA, or CBAP); Six Sigma or Lean certification preferred
 
#LI-HYBRID
 
Minimum Education Requirements: 
High school degree or equivalent required unless otherwise noted above
 
Location Boston Time Type Full time
 
Salary Range: $127,620.00 - $155,980.00
 
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 the confidence gap and imposter syndrome can 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 our Company Culture page. If this sounds like something you’d like to be a part of, we’d love to hear from you. You can also join our Talent Community to 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.

Sr. Salesforce Business Analyst

Ready to help us transform healthcare? Bring your true colors to blue.
 The Financial and Evaluation Measurement team is seeking a Data Scientist with strong technical expertise and a background in a quantitative discipline. In this role, you’ll work with large, complex healthcare datasets to project and evaluate the financial impact of policy changes, clinical programs, and third-party solutions. You’ll design analytical models and compelling visualizations that inform key business decisions, helping shape strategies to lower costs and improve the quality of care for our members.
 
This role is eligible for our Flex Persona, with candidates local to our Boston or Hingham office preferred.
 
Your Day to Day
 Analyze large, complex datasets from a robust Enterprise Data Warehouse to identify drivers of healthcare cost trends, market pressures, and profitability.
 Design and execute advanced statistical models and predictive analytics to inform financial projections and evaluate cost/benefit of business initiatives.
 Create clear, compelling data visualizations and communicate actionable recommendations that reduce healthcare costs and improve member outcomes.
 Lead cross-functional analytic projects from design through implementation, ensuring consistent representation of financial performance across the organization.
 Partner closely with teams including Payment Integrity, Health and Medical Management, Provider Contracting, and others, to ensure alignment between analytics and business strategy.
 
We’re Looking For
 Bachelor’s degree in Mathematics, Statistics, Data Science, Economics, Healthcare Analytics, or related field required. Master’s degree preferred.
 5+ years of professional experience in data science, healthcare analytics, or a related field.
 Proficiency in SQL, Python and/or R for data extraction, manipulation, and modeling.
 Experience with data visualization tools (e.g., Tableau, Power BI).
 Familiarity with SAS is a plus but not required.
 Strong analytical and problem-solving skills with attention to detail.
 Excellent communication skills—able to distill complex analyses into clear, actionable insights for non-technical audiences.
 The proven ability to manage multiple projects and meet deadlines in a fast-paced environment.
 A collaborative mindset and adaptability to shifting business priorities.
 
What You Bring
 A passion for using data to improve healthcare quality and affordability.
 A creative, solution-oriented approach to complex business problems.
 The ability to influence decision-making through clear data-driven insights and strong stakeholder partnerships.
 A team-first perspective with a proven record of driving projects to completion and measurable impact.
 
What You'll Gain
 You will design and validate analytic frameworks, uncover emerging drivers of healthcare cost and utilization, and deliver insights that shape strategy in pricing, product development, financial planning, and forecasting.
 
The Financial and Evaluation Measurement team executes innovative analytics to inform corporate strategy in critical areas including competitiveness, affordability, profitability, provider payment reform and health care policy. As Data Scientist on this team, you will work with a rich dataset and a robust well-established Enterprise Data Warehouse to identify emerging drivers of health care trend and cost, market pressures, and profitability.
 
#LI-Hybrid
 
Minimum Education Requirements: 
High school degree or equivalent required unless otherwise noted above
 
Location Boston Time Type Full time
 
Salary Range: $116,190.00 - $142,010.00
 
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 the confidence gap and imposter syndrome can 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 our Company Culture page. If this sounds like something you’d like to be a part of, we’d love to hear from you. You can also join our Talent Community to 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.

Data Scientist

Join Blue Cross Blue Shield of Massachusetts and explore 4   exciting career opportunities. They're hiring for various roles with options for remote or on-site work. Apply today and become part of their innovative team.

Blue Cross Blue Shield of Massachusetts

About Company

RN Utilization Management Reviewer

PT Utilization Management Reviewer

Sr. Salesforce Business Analyst

Data Scientist