Specialist, Utilization Management (Remote)

About the position

The Utilization Review Specialist at CareFirst BlueCross BlueShield is responsible for performing comprehensive reviews to determine the appropriateness of care and benefit coverage for medical and behavioral health services. This role leverages clinical expertise and critical thinking to analyze clinical information and regulatory requirements, ensuring that care provided aligns with established guidelines and standards. The position is remote but requires occasional in-person attendance at CareFirst locations for meetings and training.

Responsibilities
? Perform prospective, concurrent, and retrospective reviews for authorization and appropriateness of care determination.
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? Analyze clinical information, contracts, mandates, and medical policies to determine the appropriateness of clinical services.
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? Collaborate with medical directors and other departments to ensure appropriate benefit application.
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? Conduct research on diseases, treatments, and technologies to support decision-making.
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? Coordinate case rate negotiations between providers and facilities.
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? Provide assistance to members and providers regarding alternative care settings.
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? Present educational topics related to cases and treatment modalities to interdepartmental audiences.

Requirements
? Bachelor's Degree in Nursing or equivalent experience (4 years relevant work experience in addition to required work experience).
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? 5 years of clinical nursing experience.
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? 2 years of care management experience.
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? Registered Nurse (RN) license or Licensed Practical Nurse (LPN) license required upon hire.

Nice-to-haves
? Working knowledge of managed care and health delivery systems.
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? Knowledge of CareFirst clinical guidelines and medical policies.
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? Familiarity with CareFirst IT and Medical Management systems.

Benefits
? 401(k)
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? 401(k) matching