Clinical Nurse - Utilization Management / Care Management New

Job Title: Clinical Nurse - Utilization Management / Care Management

Duration: 9Months+

Location: Baltimore, MD

Notes

Candidate must reside within the DMV.

This is a hybrid role where the resource will be required to come to Baltimore, MD.

Purpose

Utilizing key principles of utilization management, the Utilization Review Specialist will 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 contribute to determination of appropriateness and authorization of clinical services both medical and behavioral health.

Essential Functions

50% Determines medical necessity and appropriateness by referencing regulatory mandates, contracts, benefit information, Milliman Care Guidelines, Apollo Guidelines, ASAM (American Society of Addiction Medicine), Medicare Guidelines, Federal 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.) Follows NCQA Standards, CareFirst Medical Policy, all guidelines and departmental SOPS to manage their member assignments. Understands all CareFirst lines of business to include Commercial, FEP, and Medicare primary and secondary policies.

30% Conducts 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. Collaborates with medical directors, sales and marketing, contracting, provider and member services to determine appropriate benefit application. Applies sound clinical knowledge and judgment throughout the review process. Coordinates non-par provider/facility case rate negotiations between Provider Contracting, providers and facilities. Follows member contracts to assist with benefit determination.

20% Makes appropriate referrals and contacts as appropriate. Offers assistance to members and providers for alternative settings for care. Researches and presents educational topics related to cases, disease entities, treatment modalities to interdepartmental audiences.

Qualifications

Education Level: Bachelor's Degree

Education Details: Nursing

Experience: 5 years Clinical nursing experience

2 years Care Management

In Lieu of Education: In lieu of a Bachelor's degree, an additional 4 years of relevant work experience is required in addition to the required work experience.

Preferred Qualifications

Working knowledge of managed care and health delivery systems.

Thorough knowledge of CareFirst clinical guidelines, medical policies and accreditation and regulatory standards

Working knowledge of IT and Medical Management systems, familiarity with web-based software application environment and the ability to confidently use the internet as a resource.

Excellent analytical and problem-solving skills to judge appropriateness of member services and treatments on a case by case basis, Proficient

Additional Skills

MCG; Altruista-Guiding Care; Case Management; Utilization Management;

Licenses/Certifications

RN - Registered Nurse - State Licensure And/or Compact State Licensure Upon Hire Req or

LPN - Licensed Practical Nurse - State Licensure

CNS-Clinical Nurse Specialist Pref