PRINCIPAL ACCOUNTABILITIES: Under the direction of the Manager of the Clinical Medical Review Section, the incumbent’s accountabilities include, but are not limited to, the following:

Primary supervisory functions of personnel issues, performance management and quarterly, bi-annual and yearly performance assessments, growth and training, and budgets.  Acts as resource to Lead CMR Specialist, Sr. CMR Specialist, and CMR Specialists (RN’s), Ops Coordinators, Clinical Review Resolution Analysts, and Business Analysts.  In addition, acts as resource to other Medical areas, Legal and Legislative Affairs, Claims and Service Departments, Marketing and Sales to interpret medical policy, advise on procedures or assist with sensitive issues to resolve conflicts with our applicants, members, brokers or providers. Supports and provides training to the professional community or in house staff in other areas as necessary.  Handles projects as requested by Management.

Performs and creates the necessary/required audit tools for the continued quality review function in the unit.  These quality review audit tools will act as staff feedback, and will be monitored for timeliness and completeness.

Handles telephone inquiries from applicants, members, brokers, attorneys and providers regarding requests to speak with management.  Must discuss confidential and sensitive issues with all listed above and resolve their complaints.

Assists in training of the Clinical Medical Review staff with materials either developed by manager, self, team lead or other sources.  Keeps detailed tracking in associate files as it relates to training efforts and progress.

Attends meetings, testing and or training with internal and external customers, to improve or design workflows for section and customers.

Assists in the development of the Corporate Medical Underwriting Criteria to be used by staff to assess potential adverse risk selection.  Tracks trending of data elements potential elimination of unnecessary routes to CMR from ASUs.

Assists in the development of new work flows and implementation of such work flows to improve productivity within the section.  Work with outside vendors or consultants to ensure the needs of the section are identified and met.

QUALIFICATION REQUIREMENTS:

Required: This position requires a Registered Nurse license in the State of Maryland with a minimum of 10-15 years of medical-surgical experience. A minimum of 5 years experience in Medical Review, Utilization Management or Care Management at CareFirst or other managed care entities. This position requires 3 years of supervisory experience, managing 10+ exempt and non-exempt Associates. Ability to manage multiple priorities. Excellent analytical skills required for complex and detailed responses.

Abilities/skills:  Excellent analytical and problem solving skills needed to assess the medical necessity and appropriateness of patient care and treatment on a case by case basis. Thorough knowledge of current standards of medical practice and insurance benefit structures. Must possess proven judgment and decision making ability. Must be able to evaluate demands on time, establish and manage appropriate priorities. The ability to evaluate, interpret and apply, established policies, federal and state laws resulting in an outcome that is congruent with the Corporate and divisional standards and regulatory mandates. Position requires excellent communication skills, which includes verbal and written abilities in order to communicate effectively with internal and external customers.  Must have superior public speaking ability.  Many contacts regarding appeals are confrontational in nature and require strong problem solving abilities and tact.  Must be able to resolve these situations independently, due to the nature of the quick responses needed to members, attorney, physicians, hospitals and other facilities.  Must have ability to build and maintain key relationships in the community.  Strong interpersonal, communication skills, with a specific focus on coaching, training, and staff development. Must maintain a ready command of a continuously expanding knowledge base of current medical and psychiatric practices and procedures, including current medical procedural terminology, surgical procedures, diagnostic entities and their complications. Must maintain awareness of current legislation that impacts the Appeal & Grievance process.

Preferred: BS/MSN Degree, or related field, and Certified Case Manager (CCM) or Legal Nurse  Consultant Certified (LNCC)certification.