Resp & Qualifications

PURPOSE:

Supervise the daily operations of the utilization management (UM) department functions to ensure appropriate coordination of health care services and compliance with UR policies/procedures, as well as, regulatory and CareFirst's accreditation standards.

PRINCIPAL ACCOUNTABILITIES:

This position reports to the Utilization Review Manager. Primary accountabilities include, but are not limited to, the following:

Manages the delegation of assignments and supervises UR associates. Routinely assesses and evaluates UR associate workloads/functions for compliance to process and standards, appropriateness in quality of work and productivity. Assists/directs handling of complex cases to ensure appropriateness for documentation and inclusion of other internal departments, including but not limited to Physician Reviewers, Central Appeals, etc. Collaborates and acts as a resource to UR staff and other internal customers regarding UR process, including, but not limited to, benefit contracts, coordination of care, adverse decisions, problem solving, or development of interdepartmental workflows. Performs Utilization Review when coverage warrants.

Provides mentoring and guidance to develop, expand and improve associates' skills and expertise. Conducts individual and regular staff meetings to maintain ongoing communication. Conducts inter-rater reviews, providing feedback on a quarterly basis or more often as indicated by performance. Ensures that UR associates have the information and resources needed to accomplish their assignments. Works with UR Supervisors and/or trainer to coordinate the orientation program for new associates, including evaluation of new associate performance as per UR policy/procedures.

Actively participates in the development, design, and implementation of utilization review processes and procedures or new CareFirst programs as assigned by Manager. Maintains UR policies and procedures to ensure UR process and goals are supported; this includes an annual review of policies and procedures. Maintains current knowledge of regulatory and/or accreditation standards. Ensures that the required elements for the standards are current and incorporated in the UR process. Performs projects or other tasks as delegated. Uses/analyzes UR data to provide insight regarding trends, staffing, case load ratio, etc., that could impact the UR process. Performs projects or other tasks as delegated.

Communicates in a timely manner to Manager appropriate information including, but not limited to, customer/case issues, reports, trends/variances, action plans, etc. Meets routinely with peers, staff and/or Manager to communicate/update as pertinent. Acts as a liaison with external customers to ensure coordination of care and services as appropriate for effective management of benefits and quality of care. Plans and implements meetings with provider community to proactively facilitate change, improve service and coordinate UR activities.

QUALIFICATION REQUIREMENTS:

Required:

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.

This position requires an active RN license in the CareFirst region with five years of medical/surgical experience including, but not limited to, inpatient care, outpatient/home care and hospice care, three years experience reviewing patient medical care and one year in a supervisory role or equivalent work experience in team leadership, training or project management.

Licenses and Certifications
RN - Registered Nurse - Maryland, Washington, DC or Compact State

Preferred Qualifications:

Bachelor's degree in Nursing with one to two years of experience in managed care. Thorough knowledge of CareFirst clinical guidelines, medical policies and accreditation and regulatory standards relating to utilization review. Experience in claims review and in using, diagnosis and procedure codes.

Knowledge, Skills and Abilities (KSAs

Knowledge of accreditation standards and federal/state regulations and general principles relating to
utilization review. Advanced
Computer skills, including Microsoft Office programs. Proficient
Ability to mentor and coach associates to accomplish goals, provide objective evaluation of associate
performance, and implement strategies to improve individual and team-based performance as needed. Proficient
Ability to multitask, prioritize and maintain a dynamic personal organization system that allows for
flexibility Expert
Excellent analytical, problem-solving skills with ability to judge appropriateness of member services and
treatments on a case by case basis Expert
Effective written and interpersonal communication skills to engage with members, healthcare
professionals, and internal colleagues Advanced

Additional Skills and Abilities
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. Must be able to effectively work in a
fast-paced environment with frequently changing priorities, deadlines, and workloads that can be variable for long
periods of time. 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.

Department

Department: MD Medicaid -HEALTH SERVICES

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: 12/31/21

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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