Utilization Management Jobs in Maryland (NOW HIRING)

Our client, a Health Insurance company, is looking for a Spec, Utilization Management for their remote location. Responsibilities include utilizing key principles of utilization management to perform prospective, concurrent, and retrospective reviews for authorization, appropriateness of care determination, and benefit coverage. Leveraging clinical expertise and critical thinking skills, the Utilization Review Specialist will analyze clinical information, contracts, mandates, medical policy, evidence-based published research, national accreditation, and regulatory requirements to determine the appropriateness and authorization of clinical services both medical and behavioral health.

The role requires determining medical necessity and appropriateness by referencing regulatory mandates, contracts, benefit information, Milliman Care Guidelines, Apollo Guidelines, ASAM (American Society of Addiction Medicine), Medicare Guidelines, client Employee Program and Policy Guidelines, Medical Policy, and other accepted medical/pharmaceutical references (i.e. FDA, National Comprehensive Cancer Network, Clinical trials, Gov, National Institute of Health, etc.). The candidate must follow NCQA Standards, CareFirst Medical Policy, all guidelines, and departmental SOPS to manage member assignments. They should understand all CareFirst lines of business to include Commercial, FEP, and Medicare primary and secondary policies.

The candidate will conduct research and analysis of pertinent diseases, treatments, and emerging technologies, including high cost/high dollar services to support decisions and recommendations made to the medical directors. They will collaborate with medical directors, sales and marketing, contracting, provider, and member services to determine appropriate benefit application. The role also involves applying sound clinical knowledge and judgment throughout the review process, coordinating non-par provider/facility case rate negotiations between Provider Contracting, providers, and facilities, and following member contracts to assist with benefit determination.

The candidate will make appropriate referrals and contacts as appropriate, offering assistance to members and providers for alternative settings for care. They will research and present educational topics related to cases, disease entities, treatment modalities to interdepartmental audiences.

Requirements include five years of clinical nursing experience, two years of care management, and in lieu of a Bachelor's degree, an additional four years of relevant work experience is required in addition to the required work experience. Preferred qualifications include working knowledge of managed care and health delivery systems, thorough knowledge of CareFirst clinical guidelines, medical policies, and accreditation and regulatory standards, and working knowledge of CareFirst IT and Medical Management systems, familiarity with web-based software application environment and the ability to confidently use the internet as a resource.

Knowledge, skills, and abilities (KSAs) include effective written and interpersonal communication skills to engage with members, healthcare professionals, and internal colleagues, strong assessment skills with the ability to make rapid connection with Member telephonically, the ability to work effectively with large amounts of confidential member data and PHI, the ability to prioritize workload during heavy workload periods, the ability to multitask, prioritize and maintain a dynamic personal organization system that allows for flexibility, proficiency in the use of web-based technology and Microsoft Office applications such as Word, Excel, and PowerPoint, and excellent analytical and problem-solving skills to judge appropriateness of member services and treatments on a case by case basis.

The incumbent is required to immediately disclose any debarment, exclusion, or other event that makes them ineligible to perform work directly or indirectly on client programs. They must be able to effectively work in a fast-paced environment with frequently changing priorities, deadlines, and workloads that can be variable for long periods of time. They must be able to meet established deadlines and handle multiple customer service demands from internal and external customers, within set expectations for service excellence. They 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.

Licenses/certifications required include RN - Registered Nurse - State Licensure And/or Compact State Licensure Upon Hire Req or LPN - Licensed Practical Nurse - State Licensure. CNS-Clinical Nurse Specialist is preferred. Additional skills include RN license, utilization management, and computer skills.

Why should you apply? Health benefits, referral program, and excellent growth and advancement opportunities.