Remote Utilization Review Jobs in Crofton, MD (NOW HIRING)

Resp & Qualifications

This role requires candidates to be located in the Maryland, Washington, DC, or Northern Virginia (DMV) area.

PURPOSE: 
This position will support the Medicare Advantage line of business. Under minimal supervision, the Care Manager researches and analyzes a member's medical and behavioral health needs and healthcare cost drivers. The Care Manager works closely with members and the interdisciplinary care team to ensure members have an effective plan of care and positive member experience that leads to optimal health and cost-effective outcomes. The ideal candidate will have previous experience with Medicare and/or Medicare Advantage patient populations with multiple co-morbidities, complex needs, social determinants of health and/or barriers to care.  

We are looking for an experienced Registered Nurse to work remotely within the greater Baltimore/Washington metropolitan area. While this position is remote, the incumbent will be expected to come into a CareFirst location periodically for meetings, trainings and/or other business-related activities.
ESSENTIAL FUNCTIONS:

• Identifies members with acute/complex medical and/or behavioral health conditions.  Engages onsite and/or telephonically with member, family and providers to develop a comprehensive plan of care to address the member's needs at various stages along the care continuum. Identifies relevant CareFirst and community resources and facilitates program, network, and community referrals.
• Collaborates with member and the interdisciplinary care team to develop a comprehensive plan of care to identify key strategic interventions to address member's medical, behavioral and/or social determinant of health needs. Engage members and providers to review and clarify treatment plans ensuring alignment with medical benefits and policies to facilitate care between settings. Monitors, evaluates, and updates plan of care over time focused on member's stabilization and ability to self-manage. Ensures member data is documented according to CareFirst application protocol and regulatory standards. 

QUALIFICATIONS:
Education Level: High School Diploma or GED.

Licenses/Certifications Upon Hire Required:

• RN - Registered Nurse - State Licensure And/or Compact State Licensure RN- Registered Nurse in MD, VA or Washington.

Experience: 5 years clinically related experience working in Care Management, Discharge Coordination, Home Health, Utilization Review, Disease Management or other direct patient care experience. 

Preferred Qualifications:

• Bachelors degree in nursing 
• CCM/ACM or other RN Board Certified certification in case management.  
• Previous experience with Medicare and/or Medicare Advantage patient populations with multiple co-morbidities, complex needs, social determinants of health and/or barriers to care.  
• Skilled in typing and working within various web-based platforms 

Knowledge, Skills and Abilities (KSAs)

• Knowledge of clinical standards of care and disease processes.
• Ability to produce accurate and comprehensive work products with minimal direction.
• Ability to triage immediate member health and safety risks.
• Basic understanding of the strategic and financial goals of a health care system or payor organization, as well as health plan or health insurance operations (e.g. networks, eligibility, benefits).
• Excellent verbal and written communication skills, along with the telephonic and keyboarding skills necessary to assess, coordinate and document services for members.
• Knowledgeable of available community resources and programs.
• Proficient in the use of web-based technology and Microsoft Office applications such as Word, Excel and PowerPoint.
• Ability to provide excellent internal and external customer service.
• 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: 72,360 - 143,715

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

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