Specialist, Utilization Management (Remote)
About the position Responsibilities • Perform prospective, concurrent, and retrospective reviews for authorization and appropriateness of care determination. • Analyze clinical information, contracts, mandates, and medical policies to determine the appropriateness of clinical services. • Collaborate with medical directors and other departments to ensure appropriate benefit application. • Conduct research on diseases, treatments, and technologies to support decision-making. • Coordinate case rate negotiations between providers and facilities. • Provide assistance to members and providers regarding alternative care settings. • 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). • 5 years of clinical nursing experience. • 2 years of care management experience. • 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. • Knowledge of CareFirst clinical guidelines and medical policies. • Familiarity with CareFirst IT and Medical Management systems. Benefits • 401(k) • 401(k) matching Apply tot his job