Lead Utilization Management Generalist



Found in: beBee S US


Resp & Qualifications

Utilizing key principles of utilization management, the Utilization Review Specialist will perform prospective,
concurrent and retrospective reviews for authorization, appropriateness of care determination and benefit coverage.
Leveraging clinical expertise and critical thinking skills, the Utilization Review Specialist, will analyze clinical
information, contracts, mandates, medical policy, evidence based published research, national accreditation and
regulatory requirements contribute to determination of appropriateness and authorization of clinical services both
medical and behavioral health.
Weight Essential Functions
50% Determines medical necessity and appropriateness by referencing regulatory mandates, contracts, benefit
information, Milliman Care Guidelines, Apollo Guidelines, ASAM (American Society of Addiction Medicine),
Medicare Guidelines, Federal Employee Program and Policy Guidelines, Medical Policy, and other
accepted medical/pharmaceutical references (i.e. FDA, National Comprehensive Cancer Network, Clinical
trials.Gov, National Institute of Health, etc.) Follows NCQA Standards, CareFirst Medical Policy, all
guidelines and departmental SOPS to manage their member assignments. Understands all CareFirst lines
of business to include Commercial, FEP, and Medicare primary and secondary policies.
30% Conducts research and analysis of pertinent diseases, treatments and emerging technologies, including
high cost/high dollar services to support decisions and recommendations made to the medical directors.
Collaborates with medical directors, sales and marketing, contracting, provider and member services to
determine appropriate benefit application. Applies sound clinical knowledge and judgment throughout the
review process. Coordinates non-par provider/facility case rate negotiations between Provider Contracting,
providers and facilities. Follows member contracts to assist with benefit determination.
20% Makes appropriate referrals and contacts as appropriate. Offers assistance to members and providers for
alternative settings for care. Researches and presents educational topics related to cases, disease entities,
treatment modalities to interdepartmental audiences.
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The
requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable
accommodations may be made to enable individuals with disabilities to perform the essential functions.
Education Level: Bachelor’s Degree
Education Details: Nursing
Experience: 5 years Clinical nursing experience
2 years Care Management
In Lieu of Education
In lieu of a Bachelor’s degree, an additional 4 years of relevant work experience is required in addition to the
required work experience.
Preferred Qualifications
Working knowledge of managed care and health delivery systems.
Thorough knowledge of CareFirst clinical guidelines, medical policies and accreditation and regulatory standards
Working knowledge of CareFirst IT and Medical Management systems, familiarity with


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