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Resp & Qualifications

PURPOSE:

The role of the Nurse, Quality Review Utilization Management (UM) is to evaluate clinical quality and procedures within the Utilization Management (UM) program to maximize efficiency, ensure compliance and optimize patient care and safety. This position supports utilization management across all lines of business including Medicare, Medicaid and Commercial product lines. The incumbent performs comprehensive audits of utilization management transactions, reviewing systems and procedures to ensure compliance with regulations, accrediting body requirements, and company standards. These audits focus on regulatory and accreditation standards as well as key risk areas that impact outcomes, compliance and patient safety.

Serves as a subject matter expert and actively participates in projects and accreditation activities. Collaborates with utilization management to develop procedures and reinforce quality standards to support critical-thinking skills and provide and/or facilitate additional training as needed for compliance with regulatory and accreditation requirements and achieve optimal performance. We are looking for an experienced clinician 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:

+ Reviews pre-authorization case files, departmental workflows and audits to ensure accuracy and compliance with federal and state regulations, accrediting bodies (e.g. NCQA) and company policies and procedures as determined by the pre-authorization management team. Develops, updates, and maintains systematic audit tools to measure compliance with UM Standard Operating Procedures, regulatory requirements and accreditation standards. Utilizes audit tools to identify areas of opportunity for quality improvement that support optimal, cost-effective health and safety outcomes for members. Assists in the development and implementation of special projects and participates in departmental and divisional initiatives. Contributes to SOP development and alignment and supports the creation and implementation of new methods, processes and tools to enhance quality improvement. Routinely monitors and analyzes UM reports, performing both quantitative and qualitative data analysis to identify trends and compliance gaps. Assists in preparation for and participates in external audits as needed. Ensures timely documentation and reporting of audit findings in accordance with organization standards.

+ Trends audit results and prepare reports and presentations highlighting strengths and areas of opportunity for improvement to promote optimal member outcomes. Conducts root cause analysis and collaborates on corrective action plans targeting identified issues. Monitors the effectiveness of corrective actions through follow-up audits and metric tracking to ensure resolution. Recommend strategies for improvement to the UM management team and partners with the training team to develop educational resources for UM staff. Provides structured one-to-one coaching and feedback sessions as needed. Creates and implements quality improvement action plans for individuals and teams, monitors progress and adjusts interventions as necessary to achieve desired outcomes. Conducts re-audits to evaluate effectiveness of improvement measures. Participates in improvement committees and contributes to organizational quality initiatives.

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.

Licenses/Certifications Upon Hire Required:

+ Health Services\RN - Registered Nurse - State Licensure and/or Compact State Licensure.

**Experience:** 5 years Clinical nursing experience with minimum of 3 years in utilization management. Minimum of 3 years quality auditing and improvement, training, mentoring, coaching, and providing feedback for improvement.

Preferred Qualifications:

+ Master's degree in Nursing.

+ Demonstrable experience with external audits, regulatory requirements and NCQA accreditation readiness.

Knowledge, Skills and Abilities (KSAs)

+ Strong understanding of NCQA standards, CMS regulations, and state/federal compliance requirements.

+ Strong understanding of NCQA standards, CMS regulations, and state/federal compliance requirements.

+ Detail-oriented with strong organizational skills and demonstrated ability to plan, organize, implement, and evaluate clinical interventions.

+ Proficiency in data analysis and reporting (Excel, audit tools).

+ Excellent written and oral communication skills including effective presentation skills. Ability to provide verbal and written feedback for improvement and formulate action plans for performance improvement. Must be able to select the appropriate mode of communication based on the subject matter.

+ Ability to analyze data, conduct root cause analysis and perform qualitative and quantitative analysis. Ability to proactively develop action plans to improve quality metrics.

+ Ability to develop reporting methods to track progress on improvement efforts.

+ Strong collaboration skills to work effectively with cross-functional teams.

+ Ability to manage multiple priorities and meet deadlines in a fast-paced environment.

**Salary Range:** $77,256 - $153,439

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 responsibilities 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

UM Quality and Reporting

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-NH2

REQNUMBER: 21631