CareFirst Careers

Utilization Review Nurse (MD Medicaid & Medicare)

Resp & Qualifications

Position Summary:
The Utilization Review Nurse will support the clinical review operations needed to assist its membership. This position is a member of a team of nurses, physicians, pharmacists, and program coordinators. This role evaluates the efficiency, appropriateness, necessity of the use of medical services, procedures, and facilities. This position is empowered to review medical services with evidenced-based criteria from one of the industry leaders of care management.

Essential Duties and Responsibilities:
Coordinate with the appropriate manager(s) on a daily basis to assess the inpatient census for appropriate alternative health care service needs.
Utilizes pre-approved criteria and guidelines to validate medical necessity of continued stay and appropriateness of treatment and discharge planning (e.g. Milliman Care Guidelines, Interqual).
Performs on-site and/or telephonic concurrent review of acute and sub-acute services, as well as precertification review for all services following the plans authorization guidelines.
Predicts and plans for patient’s needs from pre-admission, through acute and sub-acute care and post-discharge, in collaboration with the member and providers.
Coordinates with appropriate discharge planning with interdisciplinary health care team to coordinate timely discharge.
Tracks and reports trends of inappropriate utilization of resources or quality issues to the Medical Director(s).
Functions as a major contributor as it relates to discharge planning and readmission reduction strategies.
Documents all activities in the appropriate system(s) on a timely basis. Participates in rounds with the Medical Director.
Monitors and facilitates appropriate utilization of resources using evidenced-based clinical criteria. Participates in an interdisciplinary health care team to achieve positive member outcomes
Functions as a resource to the clinical team regarding approved criteria, practice guidelines and alternative treatment options.
Participates in a regular rotation of after hours/ on call

Other duties as requested or assigned related to the Utlization Review function. 

Education, Experience and Qualifications:

Degree in Nursing from an accredited college
Required to have education, training or professional experience in medical or clinical practice.
A current Registered Nurse (RN) license, without restrictions.
5 years of nursing experience (preferably in utilization management or hospital/acute care).

Proficiency in medical management for utilization review and/or medical appeals review. 

Knowledge, Skills and Abilities:

Exceptional communication skills, both written and oral, ability to positively influence others with respect and compassion; fluency in a foreign language is a plus.
Strong work ethic built on a foundation of proactivity and teamwork.
Ability to navigate ambiguity with the aid of structured problem-solving techniques.
Committed to the practice of inquiry and listening.
Willingness to “roll up one’s sleeves” and embrace the nitty gritty, bottom up task of building an organization and implementing a new model
Personal and professional track record that demonstrates a commitment to quality in health care
A positive attitude: ability to work hard, have fun, and operate efficiently in a fast paced, start up, work environment and in a highly complex and dynamic movement for health delivery reform.

Computer Skills:
Computer proficiency in Microsoft Office
Proficiency in medical management software utilized for utilization review, medical appeals, and case management.


Department: MD Medicaid - Medical

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: 5.8.21

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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