CareFirst Careers

Specialist, Utilization Management (MD Medicare Advantage)

Resp & Qualifications

PURPOSE:
Utilizing key principles of utilization management, the Utilization Review Specialist will perform prospective, concurrent and retrospective reviews for authorization, appropriateness of care determination and benefit coverage. Leveraging clinical expertise and critical thinking skills, the Utilization Review Specialist, will analyze clinical information, contracts, mandates, medical policy, evidence based published research, national accreditation and regulatory requirements contribute to determination of appropriateness and authorization of clinical services both medical and behavioral health.

ESSENTIAL FUNCTIONS:

  • Determines medical necessity and appropriateness by referencing regulatory mandates, contracts, benefit information, Milliman Care Guidelines, ASAM (American Society of Addiction Medicine), Medicare Guidelines, Medical Policy, and other accepted medical/pharmaceutical references.  Follows NCQA Standards, CareFirst Medical Policy, all guidelines and departmental SOPS to manage their member assignments. Understands Medicare Guidelines including NCD's and LCD's.

 

  • Conducts research and analysis of pertinent diseases, treatments and emerging technologies, including high cost/high dollar services to support decisions and recommendations made to the medical directors. Collaborates with medical directors, sales and marketing, contracting, provider and member services to determine appropriate benefit application. Applies sound clinical knowledge and judgment throughout the review process.  Coordinates non-par provider/facility case rate negotiations between Provider Contracting, providers and facilities. Follows member contracts to assist with benefit determination.

 

  • Makes appropriate referrals and contacts as appropriate. Offers assistance to members and providers for alternative settings for care. Researches and presents educational topics related to cases, disease entities, treatment modalities to interdepartmental audiences.


QUALIFICATIONS:

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Education Level: Bachelor's Degree
Education Details: Nursing
Experience: 5 years Clinical nursing experience
2 years Care Management
Licenses/Certifications: RN  - Registered Nurse - State Licensure And/or Compact State Licensure 
LPN - Licensed Practical Nurse - State Licensure
CNS-Clinical Nurse Specialist  
In Lieu of Education: In lieu of a Bachelor's degree, an additional 4 years of relevant work experience is required in addition to the required work experience.

Preferred Qualifications:
Working knowledge of managed care and health delivery systems.
Thorough knowledge of CareFirst clinical guidelines, medical policies and accreditation and regulatory standards
Working knowledge of CareFirst IT and Medical Management systems, familiarity with web-based software application environment and the ability to confidently use the internet as a resource.

Knowledge, Skills and Abilities (KSAs)
Effective written and interpersonal communication skills to engage with members, healthcare professionals, and internal colleagues
Must have strong assessment skills with the ability to make rapid connection with Member telephonically.
Must be able to work effectively with large amounts of confidential member data and PHI
Must be able to prioritize workload during heavy workload periods
Ability to multitask, prioritize and maintain a dynamic personal organization system that allows for flexibility
Proficient in the use of web-based technology and Microsoft Office applications such as Word, Excel and PowerPoint
Excellent analytical and problem-solving skills to judge appropriateness of member services and treatments on a case by case basis

Travel Requirements
Estimate Amount: 5% Ability to travel by own means to a variety of locations to support business needs and to attend business meetings

Department

Department: Medicare Advantage

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: 10/10/21

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.

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

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