Resp & Qualifications
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:
Department: DC Medicaid - Utilization Management
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
Please apply before: 5/14/21
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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