CareFirst Careers

Clinical Review Nurse Specialist (PreService, RN)

Resp & Qualifications


Under the supervision of the Supervisor of Pre Service Review, the incumbent’s accountabilities include, but are not limited to the following:

1. Conducts preservice reviews for assigned cases.  Determines medical necessity and appropriateness by referencing regulatory mandates, contracts, benefit information, Milliman Care Guidelines, Apollo Guidelines, Federal Employee Program and Policy Guidelines, CareFirst Medical Policy, BlueCross BlueShield Association Medical Policy, and other accepted medical/pharmaceutical references (i.e. FDA, National Comprehensive Cancer Network, Clinicaltrials.Gov, National Institute of Health, etc.) Conducts research and analysis of pertinent diseases, treatments and emerging technologies, including high cost/high dollar services to support decisions and recommendations made to the medical directors. Collaborates with medical directors, sales and marketing, contracting, provider and member services to determine appropriate benefit application. Applies sound clinical knowledge and judgment throughout the review process.  Coordinates non-par provider/facility case rate negotiations between Provider Contracting, providers and facilities. Provides clinical oversight, inventory and quality management of two outsourced vendor agreements. Communicates daily with providers, members and CareFirst Customer Service Representatives regarding medical necessity and benefits determinations. Ensures that all HIPAA confidential communication is conducted appropriately for each request. 

2. Daily uses a variety of CareFirst legacy and software systems to evaluate member product, contract and benefit eligibility. Documents findings in Medical Management web-based authorization system that supports clinical decisions, demonstrates compliance with departmental, corporate and regulatory standards, claims payment, communication and data collection ensuring that providers have accurate authorization information. Will coordinate review and authorizations for clinical services from the provider based access portal “Referral/Pre-authorization /Steerage Hub” in compliance with Medical Affairs 2012 goals.  Documents in Lotus Notes Database timely and accurately for departmental quality review process and required reporting.

3. Functions as subject matter expert resource for provider, member and inter-departmental clinical, contract and benefit inquiries.  Interacts professionally with internal and external customers such as Sales and employer group accounts. Communicates oral and written determinations in compliance with national accreditation and regulatory guidelines. Collaborates with Medical Director’s, Central Appeals, providers and insurance regulatory agencies to facilitate appropriate appeal, expedited appeal, language translation processes and to ensure that all other healthcare reform requirements and regulations are met. Makes appropriate referrals and contacts to Patient-Centered Medical Home, Care Transitions Program, Case Management, Disease Management, Central Appeals Unit, behavioral health, Pharmacy Management, Quality Improvement, Blue Distinction Centers for Transplant, Federal Government Operations of Personnel Management, National BlueCross BlueShield Association, and other programs and departments as appropriate.

4. Performs as a preceptor for new staff members as needed. Researches and presents educational topics related to complex cases, disease entities, treatment modalities to interdepartmental audiences. Participates in departmental and interdepartmental committees and work groups such as Medical Policy committee. Completes continuing education and mandatory training as scheduled.  Completes other duties as assigned.


Requires an RN degree in Nursing or equivalent experience and 7-10 years of increasingly responsible clinical related experience. At least one year of care management experience preferred.

The incumbent must have excellent analytical and problem solving skills, excellent organizational, communication skills.  Must be able to apply complex problem solving abilities to achieve problem and process solutions in order to evaluate the medical necessity and appropriateness of patient services and treatments, and interface with the multiple internal departments, medical directors and physician practices.  Excellent written and verbal communication skills are required.  This position requires a current DC, MD or VA Registered Nurse license.


Bachelor’s Degree in Nursing is preferred.  At least one year of care management experience  is preferred.  Familiarity with web based software application environment including but not limited to Milliman, Inter-Qual, and Micromedex. Ability to confidently use internet as a resource. Familiarity with business writing.


Department: Preservice Review

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:

Closing Date

Please apply before: 9/10/2018

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.


The physical demands described here are representative of those that must be met by an employee to perform the essential duties and responsibilities of the position successfully.  Requirements may be modified to accommodate individuals with disabilities.   The employee is primarily seated while performing the duties of the position.  Occasional walking or standing is required.  The hands are regularly used to write, type, organize paperwork, key and handle or feel small controls and objects.  The employee must frequently talk and hear.  The employee will frequently walk from cube to cube and occasionally take the elevator from floor to floor.  Weights of 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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