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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. We are looking for an experienced people leader and 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:

• Supervise the daily operations of the UM staff. Recruits, retains and develops a high performing team. Evaluates performance of each team member, generates development plans and sets goals within the context of the corporate policies and procedures. Ensure appropriate usage of resources in order to facilitate the UM process. Educate staff as necessary to ensure consistent performance and adhere to standards.

• Ensure compliance within applicable state program guidelines. Evaluate compliance policies and procedures and analyze/recommend enhancements.

• Assist with ensuring consistent data collection from UM staff that is used to assist the company in achieving corporate goals, to improve monitoring and reporting in order to meet external requirements

• Identify opportunities for process improvements necessary to facilitate department functions

• Communicates in a timely manner to Manager appropriate information including, but not limited to, customer/case issues, reports, trends/variances, action plans, etc.

SUPERVISORY RESPONSIBILITY:

This position manages people.

QUALIFICATIONS:

Education Level: Bachelor's Degree in Nursing or health care field 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: 3 years Medical/surgical experience including, but not limited to, inpatient care, outpatient/home care and hospice care, and experience reviewing patient medical care.

Demonstrated leadership skills.

Preferred Qualifications : Bachelors degree in Nursing.

Knowledge, Skills and Abilities (KSAs)

• Knowledge of accreditation standards and federal/state regulations and general principles relating to utilization review.

• Computer skills, including Microsoft Office programs.

• 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.

• Ability to multitask, prioritize and maintain a dynamic personal organization system that allows for flexibility.

• Excellent analytical, problem-solving skills with ability to judge appropriateness of member services and treatments on a case by case basis.

• Effective written and interpersonal communication skills to engage with members, healthcare professionals, and internal colleagues.

Licenses/Certifications Required Upon Hire:

RN - Registered Nurse - State Licensure And/or Compact State Licensure OR

LPN - Licensed Practical Nurse - State Licensure

Salary Range: $77,544 - $159,935

Travel Requirements

Estimate Amount: 5% Able to travel to CareFirst sites for meetings and off site Health Services meetings

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

MA EGWP 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.

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REQNUMBER: 20014