Utilization Management Specialist - RN (Remote)

Purpose This clinical position will support our Government Program lines of business. Utilizing key principles of utilization management, the Utilization Review Specialist (RN) will perform prospective, concurrent and retrospective reviews for authorization, appropriateness of care determination and benefit coverage. Leveraging clinical expertise and critical thinking skills, the Specialist will analyze clinical information, contracts, mandates, medical policy, evidence‑based published research, national accreditation and regulatory requirements to determine appropriateness and authorize both medical and behavioral health services. The ideal candidate will have a working knowledge of managed care and health delivery systems, and previous experience with Medicaid and DSNP populations. Essential Functions Determines medical necessity and appropriateness by referencing regulatory mandates, contracts, benefit information and accepted medical/pharmaceutical references (i.e. FDA, NCCN, Clinical Trials.gov, NIH, etc.). Follows NCQA standards, CareFirst medical policy, all guidelines and departmental SOPS to manage member assignments. Understands all CareFirst lines of business to include Commercial, FEP and Medicare primary and secondary policies. Conducts research and analysis of pertinent diseases, treatments and emerging technologies, including high-cost/high-dollar services to support decisions and recommendations made to medical directors. Collaborates with medical directors, sales and marketing, contracting, provider and member services to determine appropriate benefit application and applies sound clinical knowledge and judgment throughout the review process. 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 Education Level: Bachelor’s Degree in Nursing OR in lieu of a Bachelor’s degree, an additional 4 years of relevant work experience is required in addition to the required work experience. Experience: 5 years clinical nursing experience. 2 years care management. Licenses/Certifications: RN – Registered Nurse (state or compact license) required; LPN – Licensed Practical Nurse (state license) required. CNS – Clinical Nurse Specialist preferred. Preferred Qualifications Working knowledge of managed care and health delivery systems; prior experience with Medicaid and DSNP populations. Thorough knowledge of CareFirst clinical guidelines, medical policies and accreditation and regulatory standards. Familiarity with CareFirst IT and Medical Management systems, web‑based software applications and the ability to use the internet for research. Knowledge, Skills & Abilities (KSAs) Effective written and interpersonal communication skills to engage with members, healthcare professionals and internal colleagues. Strong assessment skills to make rapid connections with members telephonically. Ability to handle large amounts of confidential member data and PHI. Prioritization and workload management during heavy periods. Multitasking, prioritization and dynamic organization for flexibility. Proficiency in Microsoft Office applications (Word, Excel, PowerPoint) and web‑based technology. Excellent analytical and problem‑solving skills to judge appropriateness of member services and treatments on a case‑by‑case basis. Travel Requirements Estimate 5% travel by own means to a variety of locations to support business needs and attend business meetings. Salary Range $72,360 – $143,715. The disclosed range estimate has not been adjusted for location. Compensation will be based on experience, education, training and internal equity. Equal Employment Opportunity CareFirst BlueCross BlueShield is an Equal Opportunity (EEO) employer. The Company provides 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. Physical Demands The associate is primarily seated while performing the duties of the position. Occasional walking or standing is required. The associate must frequently talk and hear. Weights up to 25 pounds are occasionally lifted. #J-18808-Ljbffr