UM Generalist

Resp & Qualifications

PURPOSE:

Note: This position supports the Washington, DC Medicaid line member population.

The RN Utilization Management (UM) Generalist is responsible for completing clinical reviews, discharge planning, and appeal reviews (including inpatient and outpatient services) for appropriateness, medical necessity, and quality. The UM Generalist is knowledgeable and skilled in interpreting national guidelines such as InterQual or MCG and will refer requests for services to the Medical Director when guidelines are not met. Reviews performed by the individual in this position may be pre-service, concurrent, or retrospective in nature.  This position is part of a team of nurses, physicians, pharmacists, and non-clinical associates who work closely to care for our members.

Essential Duties and Responsibilities: 

Under the general direction of the Manager of Utilization Management or designee, the UM Generalist’s accountabilities include, but are not limited to, the following:

• Processes requests for authorization of services, including inpatient hospital admissions, re-admissions, inpatient rehabilitation services, skilled nursing admissions, home care /home infusion services, outpatient and/or inpatient services as designated.
• Documents timely within the computer based medical management system.
• Performs discharge planning to achieve safe and timely enrollee discharges from hospitals and facilities.
• Meets contractual timelines for completion of review activities.
• Communicates and interacts with providers as well as internal and external partners to facilitate and coordinate the activities of the Utilization Management process during normal business hours and during scheduled on-call shifts.
• Utilizes technology (computer-based systems) and resources to support work activities appropriately.

• Completes denial letters and communicates determinations to providers per process.
• Actively participates in all required staff meetings and complex case rounds.
• Successfully completes IRR training, exams, and testing with at least an 80% passing rate or above thresholds established by management.
• Follows all Utilization Management workflow processes.
• All other duties as assigned in support of the Utilization Management function.

Required Education/Experience/Skills/Abilities:

• 5 years clinical experience
• Active and unrestricted RN License Certification in the District of Columbia
• Within commuting distance of the D.C. office (1100 New Jersey Ave, Washington, DC).
• Experience working in a managed care environment and proficient software programs such as Microsoft Office tools.
• Ability to travel up to 10%

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: 2/10/2021

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