Resp & Qualifications
PURPOSE:
We are looking for an experienced clinical leader in the greater Baltimore metropolitan area who is willing and able to work in a hybrid model. The incumbent will be expected to work a portion of their week from home and a portion of their week at a CareFirst location based on business needs and work activities/deliverables that week.
The Director, Utilization Management provides strategic leadership of the utilization management team and is responsible for the design, assessment, implementation and outcomes of utilization management strategies using a multidisciplinary approach to enhance member engagement, improve access to quality care and the use of cost-effective health resources. Will be responsible for the Commercial, Federal Employee Program, Medicaid, and Medicare lines of business. Establishes performance metrics to ensure the needs and requirements of our members, providers, and regulators are met in accordance with accreditation standards, CMS requirements and state, Federal and local laws, and in alignment with CareFirst's business strategy. Plans, directs and evaluates the full scope of utilization management services offered and works closely with leadership, members, providers, vendors, accounts, and other strategic business partners.
This role encompasses six distinct units: Commercial UM intake and call center, Commercial outpatient medical pre-authorization review, Commercial inpatient and outpatient behavioral health review, Medicare intake and medical pre-authorization review, Medicaid / Medicare intake, and Medicaid / Medicare medical pre-authorization review. More detail can be shared during the interview process.
Plans, organizes, and manages utilization review programs. Directs the utilization of referral services. Prepares and monitors budgets for programs to report performance measurements. Enhances quality of care by assuring compliance with policies, including safety, infection control, regulatory and accreditation requirements, and quality assurance. Directs staff, assigns work, reviews and evaluates hiring methods to meet departmental needs.
ESSENTIAL FUNCTIONS:
SUPERVISORY RESPONSIBILITY:
This position manages people.
QUALIFICATIONS:
Education Level: Bachelor's Degree in Nursing OR in lieu of a Bachelor's degree, an additional 4 years of relevant work experience is required in addition to the required work experience.
Licenses/Certifications:
Experience: 8 years' Experience in a clinical and utilization review role. 3 years Management experience.
Preferred Qualifications:
Knowledge, Skills and Abilities (KSAs)
Salary Range: $128,640 - $238,788
Salary Range Disclaimer
The disclosed range estimate has not been adjusted for the applicable geographic differential associated with the location at which the work is being performed. This compensation range is specific and considers factors such as (but not limited to) the scope and responsibilites of the position, the candidate's work experience, education/training, internal peer equity, and market and business consideration. It is not typical for an individual to be hired at the top of the range, as compensation decisions depend on each case's facts and circumstances, including but not limited to experience, internal equity, and location. In addition to your compensation, CareFirst offers a comprehensive benefits package, various incentive programs/plans, and 401k contribution programs/plans (all benefits/incentives are subject to eligibility requirements).
Department
Core Clinical Operations Admin
Equal Employment Opportunity
CareFirst BlueCross BlueShield is an Equal Opportunity (EEO) employer. It is the policy of the Company to provide equal employment opportunities to all qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, protected veteran or disabled status, or genetic information.
Where To Apply
Please visit our website to apply: www.carefirst.com/careers
Federal Disc/Physical Demand
Note: The incumbent is required to immediately disclose any debarment, exclusion, or other event that makes him/her ineligible to perform work directly or indirectly on Federal health care programs.
PHYSICAL DEMANDS:
The associate is primarily seated while performing the duties of the position. Occasional walking or standing is required. The hands are regularly used to write, type, key and handle or feel small controls and objects. The associate must frequently talk and hear. Weights up to 25 pounds are occasionally lifted.
Sponsorship in US
Must be eligible to work in the U.S. without Sponsorship
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