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, Apollo Guidelines, ASAM (American Society of Addiction Medicine), Medicare Guidelines, Federal Employee Program and Policy Guidelines, Medical Policy, and other accepted medical/pharmaceutical references (i.e. FDA, National Comprehensive Cancer Network, Clinical trials.Gov, National Institute of Health, etc.) Follows NCQA Standards, CareFirst Medical Policy, all guidelines and departmental SOPS to manage their member assignments. Understands all CareFirst lines of business to include Commercial, 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 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:
Education Level: Bachelor's Degree, 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 Licensure And/or Compact State Licensure Upon Hire
LPN - Licensed Practical Nurse - State Licensure Upon Hire
CNS-Clinical Nurse Specialist- preferred
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. Must be able to meet established deadlines and handle multiple customer service demands from internal and external customers, within set expectations for service excellence. Must be able to effectively communicate and provide positive customer service to every internal and external customer, including customers who may be demanding or otherwise challenging.
Salary Range: $71,496 - $141,999
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
Salary Range Disclaimer
The disclosed range estimate has not been adjusted for the applicable geographic differential associated with the location at which the work is being performed. This compensation range is specific and considers factors such as (but not limited to) the scope and responsibilites of the position, the candidate's work experience, education/training, internal peer equity, and market and business consideration. It is not typical for an individual to be hired at the top of the range, as compensation decisions depend on each case's facts and circumstances, including but not limited to experience, internal equity, and location. In addition to your compensation, CareFirst offers a comprehensive benefits package, various incentive programs/plans, and 401k contribution programs/plans (all benefits/incentives are subject to eligibility requirements).
Department
Clinical 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.
Where To Apply
Please visit our website to apply: www.carefirst.com/careers
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 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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