Note: The job is a remote job and is open to candidates in USA. CareFirst BlueCross BlueShield is a health insurance organization seeking a Clinical Navigator (RN) to manage utilization review and concurrent inpatient care review. The role evaluates medical necessity, supports discharge planning, coordinates transitions of care, and collaborates with providers, members, families, and internal care teams to promote safe and efficient healthcare outcomes.
Responsibilities
- Utilize clinical expertise and critical thinking skills to analyze available clinical information, Electronic Medical Records (EMRs), benefit contracts, mandates, medical policy, evidence based published research, national accreditation and regulatory requirements to aid in determination of appropriateness and authorization of inpatient clinical services. Engages telephonically with member, family and providers to identify key strategic interventions, discharge planning and coordination to address members medical, behavioral and/or social determinant of health needs to promote a safe transition to the appropriate level of care and/or home
- Collaborates with CareFirst medical directors and participates in internal case rounds/discussions to determine appropriate course of action and level of care. Applies sound clinical knowledge and judgment throughout the review process. Follows member benefit contracts to assist with benefit determination
- Makes referrals to other care management programs as appropriate for chronic, long-term care coordination
- Works collaboratively with hospital teams to develop positive working relationships to decrease provider abrasion and improve the member experience
Skills
- 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
- RN - Registered Nurse - State Licensure And/or Compact State Licensure: RN - Registered Nurse in MD, VA or Washington, DC
- Experience: 5 years' clinically related experience working in Utilization Review, Care Management, and/or Home Health including Discharge Coordination
- Strong interpersonal skills and the ability to engage in a member facing environment telephonically) while at the same time building relationships and partnerships with hospital care team and alternative care delivery partners to meeting member/enrollee needs
- Strong clinical documentation skills along with the ability to type on a computer keyboard with ease and speed
- Proficient in the use of web-based technology and Microsoft Office applications such as Word, Excel and Power Point
- Strong analytical and problem-solving skills to judge appropriateness of member services and treatments on a case-by-case basis
- Knowledge of clinical standards of care and disease process and national, evidence based clinical guidelines and hospital operations
- Knowledge of available community resources and programs
- Basic understanding of the strategic and financial goals of a health care system, payer organization, health plan and/or health insurance operations (e.g. networks, eligibility, benefits)
- 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
- The candidate's primary residence must be within the greater Baltimore metropolitan area
- Must be eligible to work in the U.S. without Sponsorship
- The associate is primarily seated while performing the duties of the position. Occasional walking or standing is required. The hands are regularly used to write, type, key and handle or feel small controls and objects. The associate must frequently talk and hear. Weights up to 25 pounds are occasionally lifted
- Previous experience performing utilization review in a payor organization. Knowledge and experience with MCG
- Experience working with Commercial and Federal Employee Program employee group member and Medicare/Medicaid enrollees and benefits contracts
- MCG certification
Benefits
- Remote work arrangement, with periodic attendance at the CareFirst office for meetings, training, or other business-related activities
- CareFirst offers a comprehensive benefits package, subject to eligibility requirements
- Various incentive programs/plans, subject to eligibility requirements
- 401k contribution programs/plans, subject to eligibility requirements
Company Overview