CareFirst Careers

Clinical Review Specialist

Resp & Qualifications


1. Receive, research, review and analyze professional and institutional claims and customer inquiries that require medical expertise and knowledge for processing and/or adjudication.  Review claims for medical appropriateness, proper billing, medical necessity, pre-existing, cosmetic, experimental/investigational, compliance with health care policy, Carefirst BCBS coding guidelines and contract benefits within timeframes established by the accounts, the department and Operations. This includes interpreting and analyzing medical information such as, operative, laboratory, radiology and pathology reports, consultations, and medical progress notes to determine applicability of benefits.  Prepares cases as necessary for physicians in community in which their expertise is required.  Interpret contract language and benefit structure as necessary.  Prepare denial letters to all appropriate parties within the department time frames describing the reason or criteria used for denial. Refers appropriate cases to Quality Improvement and/or Special Investigations.

2. Assist with pricing of procedure codes which require individual consideration or are listed as “not otherwise classified” in CPT manual.  Must be able to interpret medical information and make comparison to similar or like procedures.

3. Perform medical underwriting by reviewing applications of potential subscribers, as well as any appropriate medical records.  If applicant does not meet criteria for coverage that was applied for, prepares written explanation advising reason for adverse decision and other options available. Assign appropriate subscription rate load for small groups based upon medical underwriting review.  Contributes to enhancement of Corporate goals and integrated delivery systems by providing timely decisions, being available for customer inquiries related to MU decisions and providing timely feedback to Senior Clinical Review Specialist and Supervisors when issues with system updates occur.

4. Review claims history of new medically underwritten subscribers to determine if investigation for misrepresentation is appropriate.  If investigation for misrepresentation is appropriate, requests necessary medical records and any explanation from Member.  Cancels contract when appropriate, advising Member of findings.

5. Participates in medical policy meetings, nurses’ forums, and review sessions with Medical and Dental directors, special projects, task forces, committees as assigned. Assists in development and communication of health care policy or Corporate Medical Underwriting criteria changes.  Makes recommendations on existing and new policies.  Participates in continuing education and staff development programs.  Participates in departmental quality improvement as well as department/team enhancement activities.

SCOPE DATA: Accountable for assisting the Management team in ensuring the integrity of the corporate claims reviews and medical underwriting  process at all levels, for all lines of business.  Analytical process validates corporate policies and decisions.  Failure to properly identify, investigate and process disputed issues according to established corporate policies and procedures, as well as State and Federal regulations and mandates, will result in corporate non-compliance with external regulatory review agencies and decrease member and provider satisfaction and impact NCQA accreditation.

Required:  The incumbent must be a licensed Registered Nurse who possesses a college degree.  Must have 3-5 years of acute clinical experience, previous case management, discharge planning or utilization review experience. 


  • The incumbent must be self-directed with an ability to work independently. 
  • Must have excellent organizational skills, analytical and problem solving skills. 
  • Must be able to evaluate demands on time and establish and manage appropriate priorities.
  • Must maintain a ready command of a continuously expanding knowledge base of current medical and psychiatric practices and procedures, including current medical procedural terminology, surgical procedures, diagnostic entities and their complications. 
  • Working knowledge of mainframe systems in order to access relevant information necessary for the review process. 
  • Proficiency with Microsoft Word, Excel, and various CareFirst dedicated software programs.
  • Must be able to quickly adapt to dynamic environment.


Department: Clinical Medical 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: 2/28/2019

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 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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