Utilization Management Clinician – CCR

🔥 16 hours ago

🔔 Pennsylvania – Remote

🔔 Pennsylvania – Remote

💵 $33 - $62 / hour

⏰ Full Time

🟡 Mid-level

🟠 Senior

🦅 H1B Visa Sponsor

This company has sponsored H1B visas in the past.

👻 Ghost score 0%

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Capital Blue Cross

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

Founded 1938

🏥 Healthcare

💼 Consulting

🛡️ Insurance

Healthcare • Consulting • Insurance

Capital Blue Cross is a health insurance company that offers a range of health plans for individuals, families, and employers. They serve customers in Central Pennsylvania and the Lehigh Valley, focusing on providing health coverage services such as Medicare plans, student health plans, and resources for managing medical care. Capital Blue Cross positions itself as a partner in health, emphasizing support for members' overall wellness and preventive health measures.

📋 Description

• Process acute and post-acute inpatient level-of-care requests through clinical review of submitted requests and clinical records • Apply approved medical necessity criteria to determine medical necessity and appropriateness of requested services • Interpret and apply InterQual criteria, CMS guidelines, Capital Blue Cross Medical Policies, CHIP handbook, FEP Medical Policies, FEP Benefit Brochure, and ASAM guidelines as applicable • Perform high-acuity utilization management case reviews within regulatory and departmental policy frameworks • Maintain member confidentiality and comply with internal and regulatory requirements • Collaborate with UM staff, Clinical Support Specialists, and Medical Directors to make final determinations • Collaborate with Care Management staff on discharge planning and transition-of-care activities • Participate in weekly clinical rounds for complex members • Identify and refer members with complex needs to population health and/or care management programs • Identify and refer members with Potential Quality Issues through established processes • Suggest departmental process improvements and identify learning and education opportunities • Attend and participate in company and departmental meetings and training sessions • Practice within the scope of clinical license and/or certification

🎯 Requirements

• Active, current, and unrestricted Registered Nurse licensure in Pennsylvania • Certified Case Manager (CCM) or Accredited Case Manager (ACM) certification, or ability to obtain within 2 years from date of hire • Minimum 5 years’ experience working in a higher level of care clinical role, including acute care hospital or post-acute care facility • 1 year of utilization management experience in managed care • Working knowledge and operation of a personal computer • Proficiency in Microsoft Office applications • Knowledge of medical coding guidelines, including ICD-10-CM, CPT, and HCPCS codes • Working knowledge of NCQA, CMS, and other health plan utilization management regulations • Extensive knowledge of managed care principles and emerging health treatment modalities • Ability to critically think through processes, make clinically appropriate decisions, and solve problems • Ability to prioritize multiple clinical and administrative tasks and assignments • Ability to work independently and as part of a team • Ability to interact with departments to advise, educate, and/or direct members to clinical programs and services • Ability to communicate clearly and concisely in written and oral communications

🏖️ Benefits

• Medical, Dental & Vision coverage • Retirement Plan • Paid Time Off • Holidays • Volunteer time off • Incentive Plan • Tuition Reimbursement • Flexible work environment • Training and continuing education • Professional and personal growth support • Community volunteering opportunities