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Utilization Management Specialist (Remote) Id-4502

Job Description

Resp & Qualifications

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. We are looking for an experienced professional to work remotely from within the greater Baltimore metropolitan area. The incumbent will be expected to come into a CareFirst location periodically for meetings, training and/or other business-related activities.

ESSENTIAL FUNCTIONS:

SUPERVISORY RESPONSIBILITY:
Position does not have direct reports but is expected to assist in guiding and mentoring less experienced staff. May lead a team of matrixed resources.

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:
  • RN - Registered Nurse - State Licensure And/or Compact State Licensure Upon Hire Required or
  • LPN - Licensed Practical Nurse - State Licensure Upon Hire Required
  • CNS-Clinical Nurse Specialist Preferred

Experience:
  • 5 years Clinical nursing experience
  • 2 years Care Management

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 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)
  • Effective written and interpersonal communication skills to engage with members, healthcare professionals, and internal colleagues.
  • Must have strong assessment skills with the ability to make rapid connection with Member telephonically.
  • Must be able to work effectively with large amounts of confidential member data and PHI.
  • Must be able to prioritize workload during heavy workload periods.
  • Ability to multitask, prioritize and maintain a dynamic personal organization system that allows for flexibility.
  • Proficient in the use of web-based technology and Microsoft Office applications such as Word, Excel and PowerPoint.
  • Excellent analytical and problem-solving skills to judge appropriateness of member services and treatments on a case-by-case basis.
  • 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.
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Common Interview Questions And Answers

1. HOW DO YOU PLAN YOUR DAY?

This is what this question poses: When do you focus and start working seriously? What are the hours you work optimally? Are you a night owl? A morning bird? Remote teams can be made up of people working on different shifts and around the world, so you won't necessarily be stuck in the 9-5 schedule if it's not for you...

2. HOW DO YOU USE THE DIFFERENT COMMUNICATION TOOLS IN DIFFERENT SITUATIONS?

When you're working on a remote team, there's no way to chat in the hallway between meetings or catch up on the latest project during an office carpool. Therefore, virtual communication will be absolutely essential to get your work done...

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5. HOW DO YOU PROCESS INFORMATION?

Several years ago, I was working in a team to plan a big event. My supervisor made us all work as a team before the big day. One of our activities has been to find out how each of us processes information...

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This is a great question because it shows your comfort level with technology, which is very important for a remote worker because you will be working with technology over time...

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