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Resp & Qualifications

PURPOSE:

We are looking for an experienced clinical leader 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.

The Director, Utilization Management provides strategic leadership of the utilization management team and is responsible for the design, assessment, implementation and outcomes of utilization management strategies using a multidisciplinary approach to enhance member engagement, improve access to quality care and the use of cost-effective health resources. Will be responsible for the Commercial, Federal Employee Program, Medicaid, and Medicare lines of business. Establishes performance metrics to ensure the needs and requirements of our members, providers, and regulators are met in accordance with accreditation standards, CMS requirements and state, Federal and local laws, and in alignment with CareFirst's business strategy. Plans, directs and evaluates the full scope of utilization management services offered and works closely with leadership, members, providers, vendors, accounts, and other strategic business partners.

This role encompasses six distinct units: Commercial UM intake and call center, Commercial outpatient medical pre-authorization review, Commercial inpatient and outpatient behavioral health review, Medicare intake and medical pre-authorization review, Medicaid / Medicare intake, and Medicaid / Medicare medical pre-authorization review. More detail can be shared during the interview process.

Plans, organizes, and manages utilization review programs. Directs the utilization of referral services. Prepares and monitors budgets for programs to report performance measurements. Enhances quality of care by assuring compliance with policies, including safety, infection control, regulatory and accreditation requirements, and quality assurance. Directs staff, assigns work, reviews and evaluates hiring methods to meet departmental needs.

ESSENTIAL FUNCTIONS:

• Administers policies and procedures of inpatient and outpatient services.

• Determines eligibility of programs ensuring compliance with board approved regulations. Monitors changes in regulations and proposes related changes in regulations and procedures.

• Oversees the negotiations of access to care in specified targeted areas. Maintains relationships with providers who provide services to patients and pursues a responsive system for authorization of services and approved claims.

• Oversees retrospective reviews, case appeals, billing coordination, and clinical support.

• Ensure that staff is fully trained and competent on standards of practice of Utilization Management, reimbursement methodologies and treatment coding.

• Directs the strategic and the day-to-day activities of the Department, including coaching and guiding individuals and teams in order to implement departmental, divisional, and organizational mission/goals. 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. Develops annual goals, and prepares, monitors, and analyzes variances of departmental budgets in order to control and appropriately allocate resources.

• Monitors utilization patterns, such as demographics of service, revenue, and expenditures by preparing statistical reports. Presents status of key performance indicators and makes recommendations on continuous improvement opportunities to the executive leadership team.

SUPERVISORY RESPONSIBILITY:

This position manages people.

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:

• Health Services\RN - Registered Nurse - State Licensure and/or Compact State Licensure Upon Hire Required.

Experience: 8 years' Experience in a clinical and utilization review role. 3 years Management experience.

Preferred Qualifications:

• Knowledge of Medicare Advantage

• Knowledge of Medicaid Managed Care

Knowledge, Skills and Abilities (KSAs)

• Proficient in standard medical practices and insurance benefit structures.

• Proficient in utilization management processes, standards, and managed care.

• Knowledge of medical-necessity decisions (i.e., inpatient, acute, outpatient, hospice care).

• Experience in use of web-based technology and Microsoft Office applications such as Word, Excel, and Power Point.

• 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.

• Must be able to meet established deadlines and handle multiple customer service demands from internal and external customers, within set expectations for service excellence. Must be able to effectively communicate and provide positive customer service to every internal and external customer, including customers who may be demanding or otherwise challenging.

Salary Range: $128,640 - $238,788

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

Core Clinical Operations Admin

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: 20083