Remote Utilization Management Nurse Jobs in Silver Spring, MD

Resp & Qualifications

PURPOSE: 
This position will manage all key aspects of systems operations, including configuration setup, system and integration testing, production issues triage and resolution, and interface monitoring/ resolution. The Manager provides accountability for the day-to-day operational health, system stability, and continuous execution of core clinical applications in a changing healthcare environment. This role will focus specifically on optimizing end-to-end business processes within Utilization Management, Case Management, and Appeals & Grievances. The Manager is critical in ensuring systems optimization and availability in a mission-critical, high availability environment. 

This role requires candidates to be located in the Maryland, Washington, DC, or Northern Virginia (DMV) area. The incumbent will be expected to come into a CareFirst location periodically for meetings, training and/or other business-related activities
ESSENTIAL FUNCTIONS:

• Provide deep subject matter expertise in all areas of Utilization Management (UM), including pre-service, concurrent review, and inpatient management, with a specific focus on optimizing end-to-end business processes (including but not limited to data and metrics, information technology, etc.) that contributes to the effective accomplishment of tasks and goals.
• Accountable for the day-to-day operations of GuidingCare, MCG, and other clinical applications, ensuring seamless support for core plan functions including UM, Case Management (CM), and Appeals & Grievances (A&G).
• Directly manage a team of 8-12 professionals, overseeing the daily pipeline of system updates, configuration changes, system enhancements, and User Acceptance Testing (UAT) cycles.
• Drive timely project delivery and handle high operational volume by providing clear, actionable direction and oversight to the configuration and testing teams.
• Serve as the operational bridge between clinical stakeholders and technical configuration teams, independently prioritizing daily work based on business impact and medical management goals.
• Develop, maintain, and report on operational dashboards to ensure leadership has transparent tracking of system health, task execution, and team throughput.
• Manage core administrative and financial responsibilities, including accurate vendor invoice processing and budget tracking to support ongoing clinical operations.
• Serve as the subject matter expert and representative for the clinical products team across corporate initiatives and enterprise-wide projects as needed. Maintain a strong working knowledge of the FACETS claims-to-authorization matching workflow and utilize this knowledge to identify and resolve operational and system gaps.
• Build trusted relationships within CareFirst to deepen subject-matter expertise, find opportunities to synchronize with core operations, and ensure close coordination with the central team in the execution of their areas of responsibility within the division. Identifying opportunities for synergies to improve task execution across the organization.
• Ensures successful completion of day-to-day changes, corporate initiatives, and other projects by managing team and/or matrixed resources to ensure effective Systems Development Life Cycle (SDLC) activities spanning request analysis, requirements or specifications documentation, acceptance testing, development and maintenance of operating procedures operations support, and implementation impact assessment.
• Directs and participates in planning sessions to ensure that the teams operations and long-range goals are coordinated with other department staff, IT, and clients. Develops and/or assists with the development of project management plans for day-to-day changes, corporate initiatives, and other projects. Provides resource estimates, timeframes, guides cost/benefit ROI business cases, and assists with the development of budgets for initiative projects. Oversees corporate processes for systems change management, spanning request submission, review, validation, prioritization, scheduling, and status reporting.
  

SUPERVISORY RESPONSIBILITY:
This position manages people.
QUALIFICATIONS:
Education Level: Bachelor's Degree in Business Administration or related 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: 5 years Business Analysis experience. 1 year supervisory or progressive leadership experience.
Preferred Qualifications:

• Certification in applicable domain area. 
• 5 years experience in business development, operational technology support, Utilization Management (UM) operations, day-to-day clinical application management, Clinical Product Configuration, Health Plan Claims/Authorization workflows, or related healthcare consulting.
• Minimum of 3 years of operational leadership explicitly within Health Services, Medical Management, or Clinical Operations (Note: purely technical or traditional IT support backgrounds will not meet the requirements of this role). Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Knowledge, Skills and Abilities (KSAs)

• Proven ability to lead a large operational team (8-12 staff) and oversee defect triaging, release coordination, and production deployments.
• Demonstrated ability to independently translate clinical policies and business goals into daily operational execution, intuitively grasping the "why" behind UM, CM, and A&G workflows.
• Effective knowledge of Utilization Management (UM) processes (pre-service, concurrent, inpatient) and applicable regulatory requirements (e.g., CMS, state mandates, accreditation standards).
• Proficient understanding of medical coding systems (CPT, ICD-10, HCPCS) and the annual code maintenance review cycle.
• Understands business goals and priorities.
• Follows evolving market, industry and consumer trends.
• Effective communication of complex ideas both verbal and written.
• Exceptional project management, facilitation and organizational skills.
• Excellent relationship management skills.
• Strategic thinker, problem solver, and a collaborator who can drive engagement and discussions.
• Significant experience with MS Office (Excel, PowerPoint, Word).

Salary Range: 120,400 - 223,493

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 responsibilities 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).

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.

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.

#LI-SS1