Utilization Review Specialist

Utilization Review Specialist
Washington, DC

CareFirst BlueCross BlueShield, the largest health care insurer in the Mid-Atlantic region, is a company that has mastered the art of making the complex simple. Every day, we help people make decisions that will positively impact their lives today and in the future. We currently have an opportunity available for an experienced Utilization Review Specialist in Washington, DC.

This individual will:
? Receive, research, review & analyze complex professional and institutional claims and customer inquiries that require medical expertise and knowledge for proper adjudication, may use this information to determine potential adverse risk selection to Corporation.
? Review claims for medical appropriateness, proper billing, medical necessity, pre-existing, cosmetic, experimental/investigational, compliance with health care policy, Carefirst BCBS coding guidelines, contract benefits, and audits for medically underwritten subscribers.
? Interpret and analyze medical information such as operative, laboratory, radiology and pathology reports, consultations, and medical progress notes to determine applicability of benefits or potential adverse risk to Corporation.

Requires:
? BSN/CCM preferred
? 5 years acute clinical experience
? Previous case management, discharge planning, utilization review, benefits and/or claims experience
? Strong oral and written communication, interpersonal, organizational, PC and problem solving skills
? Knowledge of issues and developments in health care cost containment and
insurance reimbursement
? Knowledge of management information systems, medical coding, ICD-9 CPT, HCHP


We provide onsite educational activities,Health Insurance, Life Insurance, Tuition Reimbursement, Metrocheck (DC location), paid time off, holidays, an available fitness center and more.

For more information and/or to apply online, visit us at: www.carefirst.com and search for appropriate Req# 000360.

No phone calls, please. Principals only. EOE, M/F/D/V.