Capital Blue Cross · 6 hours ago
Utilization Management Clinician - CCR
United States
Full-time
Remote
Senior Level
5+ years expCapital Blue Cross is committed to going the extra mile for their team and community. They are seeking a Utilization Management Clinician responsible for processing acute and post-acute inpatient and select outpatient higher level of care requests through clinical review and the application of approved medical necessity criteria.
ConsultingHealth CareHealth InsuranceProfessional Services
No H1B
Responsibilities
Processes acute and post-acute inpatient medical or behavioral health and select intensive outpatient higher level of care requests through review of the submitted request and applicable clinical records and applying approved medical necessity criteria to determine medical necessity and appropriateness of the service requested
Interprets and applies InterQual criteria, CMS-issued guidelines, Capital Blue Cross Medical Policies, the CHIP handbook, FEP Medical Policies, the FEP Benefit Brochure, and/or American Society of Addiction Medicine ASAM) guidelines to these requests as applicable to the member’s product
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. Complies with both internal policies and all regulatory requirements regarding member’s confidentiality
Collaborates with UM department staff, including Clinical Support Specialists and Medical Directors to make a final determination, and with Care Management staff on discharge planning and transition of care activities
Participates in weekly clinical rounds to discuss complex members as needed and requested. Identifies and refers members with complex needs to the appropriate population health and/or care management program
Identifies and refers members with Potential Quality Issues (PQIs) through established processes to the applicable department for further review and investigation
Offers suggestions for improvement in departmental processes and identifies opportunities for learning and education
Attends and participates in company and departmental meetings and training sessions as required and requested
Practices within the scope of clinical license and/or certification
Qualification
Required
Must have 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
A minimum 5 years' experience working in a higher level of care clinical role including acute care hospital, post-acute care facility, etc. required
1 year UM experience in managed care required
Communication, technical, analytical, organizational, and other unique skills required to succeed in the position
Demonstrated ability to critically think through processes to make clinically appropriate decisions and problem solve
Demonstrated ability to prioritize multiple clinical and administrative tasks and assignments
Demonstrated ability to work independently and as part of a team
Demonstrated ability to interact with other departments actively and proactively, as needed, to advise, educate, and/or direct members to other clinical programs and services
Demonstrates openness, flexibility, problem solving, patience, and tact when interacting with members, family, providers, and peers
Demonstrated ability to communicate in a concise and clear manner in both written and oral communications
Working knowledge and operation of a personal computer, including proficiency in Microsoft Office applications
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
Extensive knowledge of managed care principles and emerging health treatment modalities
Benefits
Medical, Dental & Vision coverage
Retirement Plan
Generous time off including Paid Time Off
Holidays
Volunteer time off
Incentive Plan
Tuition Reimbursement
Company
Capital Blue Cross
At Capital Blue Cross, we promise to go the extra mile for our team and our community.
1001-5000 employees
Funding
Current Stage
Late StageLeadership Team
Todd Shamash
President and CEO
Glenn Heisey
Executive Vice President and Chief Operating Office
Recent News
2025-10-02
2022-10-14
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