Utilization Management Director

23 hours ago


Baltimore, Maryland, United States CareFirst BlueCross BlueShield Full time
Job Summary

CareFirst BlueCross BlueShield is seeking an experienced clinical leader to serve as the Director of Utilization Management. This role provides strategic leadership of the utilization management team and is responsible for designing, assessing, implementing, and evaluating utilization management strategies to enhance member engagement, improve access to quality care, and optimize the use of cost-effective health resources.

Key Responsibilities
  • Provide strategic leadership to the utilization management team, including planning, directing, and evaluating the full scope of utilization management services offered.
  • Establish performance metrics to ensure the needs and requirements of members, providers, and regulators are met in accordance with accreditation standards, CMS requirements, and state, federal, and local laws.
  • Work closely with leadership, members, providers, vendors, accounts, and other strategic business partners to achieve business objectives.
  • Oversee the design, assessment, implementation, and evaluation of utilization management strategies, including the development of policies, procedures, and guidelines.
  • Monitor utilization patterns, including demographics of service, revenue, and expenditures, and present status of key performance indicators to the executive leadership team.
Requirements
  • Bachelor's Degree in Nursing or equivalent experience.
  • 8 years of experience in a clinical and utilization review role, with 3 years of management experience.
  • Knowledge of Medicare Advantage and Medicaid Managed Care.
  • Proficient in standard medical practices and insurance benefit structures.
  • Ability to mentor and coach associates to accomplish goals, provide objective evaluation of associate performance, and implement strategies to improve individual and team-based performance as needed.
What We Offer

CareFirst BlueCross BlueShield offers a comprehensive benefits package, various incentive programs/plans, and 401k contribution programs/plans. We are an Equal Opportunity Employer and welcome applications from diverse candidates.



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