CareFirst Careers

Clinical Review Specialist Supervisor

Resp & Qualifications

 PURPOSE: The Supervisor is responsible for oversight, assessment, development, implementation, monitoring and evaluation of processes, standards, policies and procedures that result in well organized, effective, and quality review of cases.  Develops and maintains updates to Corporate policies such as, but not limited to Medical policies, FEP product policies, and policies and procedures utilized by Clinical Medical Review staff.  Monitors work performance of associates and discuss issues as necessary.  Assists in the development and implementation of corrective action plans or performance improvement plans and monitors progress during review period.  Evaluates staff on job performance and gives appropriate feedback to associate and Managers.  Acts as resource for other Care Management Areas, Legal and Legislative Affairs, Medical Directors, Claims and Service Departments, Pricing, Actuaries, as well as Sales (Group and Individual).  Prepares and presents appropriate cases to the Executive Staff, Medical Directors and/or Physician Advisors. Overall accountability for the orientation and training of new associates and development of training materials and resources.

 

PRINCIPAL ACCOUNTABILITIES MEDICAL REVIEW FOCUS:

Under the direction of the Manager, the incumbent’s accountabilities include, but are not limited to, the following:

Primary supervisory functions of personnel issues, performance management and bi-annual and yearly performance assessments, growth and training. Provides direct supervision for the activities of the CMR Specialists (RN’s).  In addition, acts as resource to other Medical areas, Legal and Legislative Affairs, Claims and Service Departments, Marketing and Sales to interpret medical policy, advise on procedures or assist with sensitive issues to resolve conflicts with our applicants, members, brokers or providers. Supports and provides training to the professional community or in house staff in other areas as necessary.  Handles projects as requested by Management.

Performs and creates the necessary/required audit tools for the continued quality review function in the unit.  These quality review audit tools will act as staff feedback, and will be monitored for timeliness and completeness.

Assists in the development and presentation of annual and semi-annual reports, compiling statistical data related to Quality of Care.

Attends meetings, testing and or training with internal and external customers, to improve or design workflows for section and customers.

Attends meetings, testing and or training with internal and external customers, to improve or design workflows for section and customers.

 Assists in the development of the Medical Policy Criteria to be used by staff to assess potential adverse risk selection.  Tracks trending of data elements potential elimination of unnecessary routes to CMR from ASUs.

 

Assists in the development of new work flows and implementation of such work flows to improve productivity within the section.  Work with outside vendors or consultants to ensure the needs of the section are identified and met.

 

Assists in training of the staff with materials either developed by manager, self, team lead or other sources.  Keeps detailed tracking in associate files as it relates to training efforts and progress.

 

QUALIFICATION REQUIREMENTS:

Required: The incumbent must be a licensed, registered nurse with a college degree or Nursing diploma.  Must have a minimum of 5 years medical-surgical experience, with at least 3 years experience in the Medical Review and/or Utilization Management area at CareFirst BlueCross BlueShield or 3 years management experience in a health care related industry.

 

Abilities/Skills: The incumbent must act as a change agent and as such must have results orientation, as well as excellent verbal and writing skills, analytical skills, interpersonal skills, organizational ability, negotiating skills, problem solving ability and budget management skills. Proven ability to coach and mentor less experienced team members.  The incumbent must have the ability to represent CareFirst BlueCross BlueShield in a professional manner both internally and externally.

 

Preferred: Knowledge of FEP systems. Inventory management experience in a Claims or Service Operations environment. Experience in performing detailed data analysis and reporting. Prior NCQA, URAC experience including knowledge of accreditation standards and requirements. Knowledge of Milliman’s HealthCare Management Guidelines, Mckesson’s ClaimCheck product and other claims processing software. 

 

Department

Department: Federal Employee Program Administration

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.

Hire Range Disclaimer

Actual salary will be based on relevant job experience and work history.

Where To Apply

Please visit our website to apply: www.carefirst.com/careers

Closing Date

Please apply before: 5/26/2018

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 have good visual acuity for computer viewing and must frequently talk and hear.  Weights of up to 25 pounds are occasionally lifted.  Local travel is required.

 

Sponsorship in US

Must be eligible to work in the U.S. without Sponsorship

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