CareFirst Careers

Clinical Director, Medicare/Medicaid Programs (Utilization Management)

Resp & Qualifications

PURPOSE: Clinical Director, Medicare/Medicaid Programs (Utilization Management)reporting to the Vice President of Care Management, provides overall strategic, clinical and operations management for the CareFirst government programs care management activities. The incumbent acts as the clinical expert responsible for providing direct management and oversight of all operations of Utilization Management and Care Management for Medicare, Medicaid and other government programs. Incumbent serves as the primary contact/liaison for all government medical management related inquiries both internally and externally. Responsibility includes oversight of the clinical support programs as it relates to the government programs population. The Director of Government Programs Medical Management establishes performance metrics to ensure we are meeting the needs and requirements of our members, providers, and regulators. Ensures that highly regulated functions such as Prior Authorization are done in compliance with state, Federal and local laws and in accordance with regulating bodies and in alignment with CareFirst’s business strategy, regulatory requirements, and CMS Stars measures.

PRINCIPAL ACCOUNTABILITIES:  Under the general direction of the VP of Care Management, the incumbent’s accountabilities include, but are not limited to, the following:

1. Development of the go-to-market Medical Management and Care Management strategies for the CareFirst Government programs.

  • Facilitates conformance to Medicare, Medicaid, NCQA and other regulatory requirements.
  • Supports, all areas of utilization management; pre-service, concurrent and retrospective review process and care management.
  • Provides professional leadership and direction in the utilization/cost management (UM) as measured by benchmarked UM goals.
  • Oversees the use of established clinical guidelines and approval/denial determinations in accordance with evidence-based standards, organizational policies and procedures, and regulatory requirements.
  • Oversees the identification of potentially unnecessary services and care delivery settings, and recommend alternatives, as appropriate.
  • Leads the creation and development of new clinical programs related to the needs of the Medicare/Medicaid population. Serves as a liaison with other departments and divisions for development and implementation of programs, products and activities. Develops and implements programs for education.
  • Accountable for all CMS and State regulatory requirements and audit support.

3. Represents government medical management/care management programs in CareFirst quality and productivity initiatives such as the Quality Improvement Committee, HEDIS, the quality scorecard (clinical) and population identification & stratification and CMS stars measures.

4. Establishes performance and outcomes metrics to evaluate the success of the Medical Management/Care Management initiatives for government programs.

5. Works closely with vendor and provider partners to ensure that the programs are followed to contract requirements and to develop and maintain business relationships in the provider communities to ensure optimal performance of the programs.
6. Staff Management

Recruits, retains and develops high performing teams of clinicians and other business professionals related to the delivery of a continuum of services and programs for the Medicare/Medicaid populations. 

  • Makes decisions regarding the hiring, promotion, development and termination of team members.
  • Reviews staffing goals and expectations to ensure that each is consistent and adequate to meet department goals. 
  • Evaluates the performance of each team member, generates development plans and sets goals within the context of corporate policy. 
  • Provides coaching, counseling and motivation to team members ensuring staff has the appropriate tools and training. 
  • Support clinical staff to work at top of license.
  • Identifies resource needs.

SUPERVISORY RESPONSIBILITY: This position will have supervisory responsibility.

Required Education/Experience/Skills/Abilities:

Bachelor of Science Nursing degree (BSN). In lieu of a degree must have 4 years related experience.  Must be a Registered Nurse with an active license to practice in Maryland and/or DC and/or Virginia and/or Delaware without restriction. 

In addition:

  • Minimum of 10 years in a managed care operational environment and at least 7 years’ experience with Medicare Advantage.
  • At least 5 years of experience as a people leader, directly managing staff.  Management experience must include responsibility for operations, staffing of both clinical and non-clinical personnel, and extensive budget responsibilities.
  • Deep understanding and experience with Medicare (CMS) utilization management (pre-service; prior authorizations)
  • Understanding of  government programs populations and the specific needs related to chronicity, frailty and social determinants.
  • Detailed knowledge of Maryland, DC and Virginia regulations, Federal regulations and CMS guidelines regarding utilization management and care management services, as well as NCQA and URAC accreditation standards for care management.
  • Demonstrated leadership experience including successful matrix management. Ability to inspire, motivate and guide others toward goal accomplishments. Ability to develop leadership in others through coaching, mentoring, rewarding and guiding associates.
  • Excellent organizational and negotiating skills. Excellent communication skills including written and presentation skills appropriate for senior level executive and stakeholder communications.
  • Strong interpersonal and associate relations skills.
  • Proven capabilities in implementing complex business strategies.
  • Demonstrated ability to develop innovative solutions through the application of advanced problem-solving skills and skilled in garnering cross-functional support as required.
  • Ability to manage operations with an extensive and varied scope.
  • The ability to maintain and build relationships within the community and the company at different organizational levels.
  • Demonstrated successful planning and organizational skills in developing and implementing strategic and tactical plans.
  • Must be able to effectively work in a fast-paced environment with frequently changing priorities, deadlines, and workloads that can be variable for long periods of time.  Must be able to meet established deadlines and handle multiple customer service demands from internal and external customers, within set expectations for service excellence.   Must be able to effectively communicate and provide positive customer service to every internal and external customer, including customers who may be demanding or otherwise challenging.


  • Medicaid and other government programs
  • Master’s in Science Nursing or related field
  • CCM Certification



Department: Medical Affairs

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: 5/23/2020

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 the incumbent to perform the essential duties and responsibilities of the position successfully.  Requirements may be modified to accommodate individuals with disabilities.
  • Must be able to work in an office setting, primarily seated while performing duties for a minimum of 8 hours per workday.
  • Must be able to provide own transportation to drive regularly to physician’s office and to satellite CareFirst Blue Cross Blue Shield offices.
  • Walking and standing are required.  Lift weight up to 25 pounds on occasion.
  • Hands are regularly used to write, type, key and handle or feel small controls and objects.  Must be able to type and to speak on the telephone simultaneously.
  • Must have the ability to communicate verbally effectively. Auditory ability to actively listen.

Sponsorship in US

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

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