Job Description Summary

The Medical Utilization Management (UM) position is responsible for all medical utilization management (UM) activities including, but not limited to, guideline development; identification, implementation, oversight, management, and evaluation of FEP UM functions and initiatives. Provides insight, direction, and supports the implementation of UM program initiatives to increase the value of services for Plans and internal customers. Evaluates new benefits for clinical and policy guidelines as part of annual benefit process with Operations, Analytics and Actuarial Services. Represents FEP as the Medical UM clinical and technical expert (SME) in all forums, managing relationships with Plan contacts and providing tactical guidance and education to Plans regarding Medical UM processes. Leads and participates in complex projects. Resource to Plans for FEP-related information regarding benefit utilization, precertification, prior authorization, and retrospective review processes. Performs annual BCBS Plan FEP Medical UM budget oversight and approval.

Responsibilities include but are not limited to:

• Leads and executes the development, implementation, and maintenance of new and existing medical utilization management processes and issues in coordination with Clinical Account Managers, FEP Member Services, Benefits, Operations, FEP Operations Center and Actuarial Services teams.
  
• Manages critical Office of Personnel (OPM) escalations that have external visibility and impacts to member and provider satisfaction, evaluating options and working with Plans for resolution. Identifies and manages risks, resolves conflicts and removes barriers that impede Plans' ability to achieve goals and performance expectations.
  
• Leads the formulation and integration of clinical utilization management program policies for the BCBS FEP Benefits and Administrative guidance to BCBS Plans for appropriate claims processing according to FEP and OPM guidance. Assesses that the UM guidelines and processes are consistent with industry standards. Keeps abreast of and interprets trends within the medical healthcare industry which could affect healthcare delivery systems, benefit coverage, provider utilization and formulates strategies to respond to trends. Represents FEP Medical UM on multiple workgroups (accreditation, FEP Pilots, FEP Policy, etc.). Manages correspondence reviews for member and utilization management inquiries, while assuring compliance with regulatory standards set forth by CMS, NCQA, ACA, FEP and BCBSA.
  
• Translates trend information into strategic action plans resulting in value-added resources and/or programs that address Plan business needs and supports Federal Employee Program (FEP) strategic initiatives. This also includes collaborating with FEP Pilot initiatives to promote creative clinical initiatives while ensuring correct Medical UM guidelines and processes. Lead or participate on team to take recommendation(s) to implementation. Keep abreast of trends within the healthcare industry which could affect benefit coverage, care delivery, provider utilization, and medical costs. Assess policies and guidelines for consistency with industry standards. Delegates key accountabilities to other team members as needed.
  
• Initiates new programs and modifications for managing utilization and cost savings. This includes developing the strategy, leading cross functional teams to create, implement and maintain utilization trends. Leveraging and interpreting utilization data, coding and policy research. Coordinates the development and maintenance of UM reporting and continuous quality improvement of FEP UM processes. Performs annual BCBS Plan FEP Medical UM budget oversight and approval.
  
• Collaborates with the Care Delivery Implementation and Benefits Operations team on initiatives to streamline medical clinical review of claims while adhering to the Accreditation (NCQA/URAC) and all applicable UM process requirements (CMS, ACA, FEP and BCBSA).
  

Required Education, Certifications and Experience

• Bachelors Degree in related discipline
  
• Active Registered Nursing License
  
• A minimum of 5 years experience with Medical Utilization Management (UM) in a managed care setting including experience with the UM standards of URAC/NCQA accreditation survey process
  
• Proficiency with the information technologies (Microsoft software applications, e.g., Word, Excel, and PowerPoint).
  
• Proven understanding of administrative databases and their application to projects, in addition to a facility with analytic tools.
  
• Demonstrated presentations skills including the ability to plan, facilitate and present at meetings, conferences and to management.
  
• Demonstrated knowledge of different business lines use of accreditation.
  
• Advanced project management skills for planning and executing multiple projects and a detail orientation to ensure compliance with accreditation standards and accuracy of statistics.
  
• Demonstrated ability to create strategies that support initiatives and translate these into action plans.
  
• Demonstrated project and resource management skill including the ability to delegate and motivate others.
  
• Demonstrated ability to handle multiple projects, prioritizing critical aspects/tasks, working under pressure and meeting deadlines.
  
• Demonstrated organization skills including the ability to prioritize and identify critical issues.
  
• Advanced analytical skills with the ability to analyze and interpret data and conduct complex analysis.
  
• Demonstrated ability to foster strong working relationships with customers and business stakeholders and contacts.
  
• Ability to interact effectively with senior management, both internal/external to the Association.
  
• Excellent communication skills, both written and oral.
  
• Ability to translate complex, technical and/or quantitative information in clear, concise and understandable documents of presentation.
  

Preferred Education, Certifications and Experience

• Masters Degree in healthcare or related field
  
• Advanced certification by Academy for Healthcare Management and/or Certified Professional in Healthcare Quality.
  
• CPT Coding certification
  
• A minimum of seven years related business experience which demonstrates knowledge and understanding of PPO operations, business practices and processes, as well as knowledge of corporate goals.
  

People Management - No