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Resp & Qualifications

PURPOSE:

Manages the utilization of referral services. Enhances quality of care by assuring compliance with policies, including safety, infection control, regulatory and accreditation requirements, and quality assurance. Manages staff, assigns work, reviews and evaluates hiring methods to meet departmental needs. We are looking for an experienced clinical leader in the greater Baltimore metropolitan area who is willing and able to work in a hybrid model. The incumbent will be expected to work a portion of their week from home and a portion of their week at a CareFirst location based on business needs and work activities/deliverables that week.

ESSENTIAL FUNCTIONS:

+ Trains staff on standards of practice of Utilization Management and reimbursement methodologies and treatment coding.

+ Manages policies and procedures of inpatient and outpatient services. Tracks service utilization within clinics by assisting within the development and implementation of procedures.

+ Analyzes eligibility of programs ensuring compliance with board approved regulations. Monitors changes in regulations and proposes related changes in regulations and procedures. Prepares analysis for leadership.

+ Maintains relationships with providers who provide services to patients and pursues a responsive system for authorization of services and approved claims.

+ Prepares retrospective reviews, case appeals, billing coordination, and clinical support.

+ Manages the analysis of utilization patterns, such as demographics of service, revenue, and expenditures by preparing statistical reports.

SUPERVISORY RESPONSIBILITY:

This position manages people.

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 Experience in a clinical and utilization review roles. 1 year demonstrated progressive leadership experience.

**Preferred Qualifications** :

+ Knowledge and experience in both government services (Medicare, Medicaid, DSNP) and commercial lines of business in a health plan setting. Experience with MCG; certification is a plus!

+ Experience with Guiding Care platform. Understanding of developing efficient processes. Strong knowledge and skills related to change management.

Knowledge, Skills and Abilities (KSAs)

+ Proficient in standard medical practices and insurance benefit structures.

+ Proficient in utilization management processes, standards, and managed care.

+ Knowledge of medical-necessity decisions (i.e., inpatient, acute, outpatient, hospice care).

+ Proficient in Microsoft Office programs.

**Licenses/Certifications Required Upon Hire** : Health Services\RN - Registered Nurse - State Licensure and/or Compact State Licensure.

Salary Range: $96,160 - $178,497

**Travel Requirements:** Occasional.

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

MD Medicaid / DSNP Clinical

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 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.

\#LI-SS1

REQNUMBER: 21126