Utilization Management Clinician – CCR

🔥 0 minutes ago

🔔 Pennsylvania – Remote

🔔 Pennsylvania – Remote

💵 $32 - $61 / hour

⏰ Full Time

🟡 Mid-level

🟠 Senior

🦅 H1B Visa Sponsor

This company has sponsored H1B visas in the past.

Apply Now

Find Similar Remote Jobs

Set Up Email Alert For New Jobs

📊 Check your resume score for this job

Improve your chances of getting an interview by checking your resume score before you apply.

Upload Resume

Capital Blue Cross

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

Founded 1938

⚕️ Healthcare Insurance

💸 Finance

👥 B2C

Healthcare Insurance • Finance • B2C

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

• Processes acute and post-acute inpatient medical level of care requests through review of the submitted request and applicable clinical records and applying approved medical necessity criteria • Interprets and applies InterQual criteria, CMS-issued guidelines, Capital Blue Cross Medical Policies, and/or American Society of Addiction Medicine ASAM guidelines • Performs high acuity of care UM case reviews within the framework of applicable regulatory requirements and established policies and procedures of Capital’s UM department • Collaborates with UM department staff, including Clinical Support Specialists and Medical Directors to make a final determination

🎯 Requirements

• 5 years’ experience working in a higher level of care clinical role including acute care hospital, post-acute care facility • 1 year UM experience in managed care • Active current and unrestricted Registered Nurse licensure in Pennsylvania • Requires Certified Case Manager (CCM) or Accredited Case Manager (ACM) certification or the ability to obtain within 2 years from date of hire • Knowledge of medical coding guidelines, including ICD-10-CD, CPT, and HCPCS codes • Working knowledge of National Committee for Quality Assurance (NCQA), CMS, and other health plan UM regulations

🏖️ Benefits

• Medical, Dental & Vision coverage • Retirement Plan • Generous time off including Paid Time Off, Holidays, and Volunteer time off • Incentive Plan • Tuition Reimbursement