Utilization Management

Position: Utilization Management
Location: Baltimore MD #REMOTE (Should come to the office for training)
Duration: Long term

Job Description:

• 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.
• Education Level: Bachelors Degree (Nursing)
• 5 years Clinical nursing experience and 2 years Care Management
• 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 webbased software application environment and the ability to confidently use the internet as a resource.
• Effective written and interpersonal communication skills to engage with members healthcare professionals and internal colleagues Proficient
• Must have strong assessment skills with the ability to make rapid connection with Member telephonically. Proficient
• Must be able to work effectively with large amounts of confidential member data and PHI Expert
• Must be able to prioritize workload during heavy workload periods Proficient
• Ability to multitask prioritize and maintain a dynamic personal organization system that allows for flexibility Advanced
• Proficient in the use of webbased technology and Microsoft Office applications such as Word Excel and PowerPoint Proficient
• Excellent analytical and problemsolving skills to judge appropriateness of member services and treatments on a case by case basis Proficient

Top 5 Required Skills:

Utilization Management experience Knowledge of Milliman Care Guidelines.

Licenses/Certifications

RN Registered Nurse State Licensure And/or Compact State Licensure Upon Hire Req or
LPN Licensed Practical Nurse State Licensure
CNSClinical Nurse Specialist

• 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 webbased software application environment and the ability to confidently use the internet as a resource

ESSENTIAL FUNCTIONS:
50% 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 FEP and Medicare primary and secondary policies.
30% 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 nonpar provider/facility case rate negotiations between Provider Contracting providers and facilities. Follows member contracts to assist with benefit determination.
20% 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.