Utilization Management Clinician – CCR

Capital Blue Cross

. Process acute and post-acute inpatient level-of-care requests through clinical review of submitted requests and clinical records .

Posted 10/13/2026full-timeRemote • Pennsylvania • United StatesMid-LevelSenior💰 $34 - $62 per hourWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in Utilization Management and Clinical Review, applying medical necessity criteria and guidelines to ensure appropriate care. Proficient in collaborating with multidisciplinary teams to enhance patient outcomes and streamline processes within regulatory frameworks.

Highest-signal resume keywords

Registered Nurse LicensureUtilization Management ExperienceCertified Case Manager (CCM)Knowledge of Medical Coding GuidelinesProficiency in Microsoft Office Applications

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Clinical ReviewMedical Necessity CriteriaInterQual CriteriaICD-10-CM CodingCPT CodingHCPCS CodingUtilization Management RegulationsManaged Care PrinciplesCritical ThinkingProblem Solving

Soft Skills

Communication SkillsTeam CollaborationIndependent WorkPrioritizationAdvising and Educating

Tools & Technologies

Microsoft OfficePersonal Computer

Certifications & Qualifications

Registered Nurse Licensure in PennsylvaniaCertified Case Manager (CCM)Accredited Case Manager (ACM)

Industry Keywords

Acute CarePost-Acute CareCMS GuidelinesNCQA RegulationsCapital Blue Cross Medical PoliciesFEP Medical PoliciesASAM GuidelinesPopulation HealthCare ManagementQuality Issues

About the role

Key responsibilities & impact

Process acute and post-acute inpatient level-of-care requests through clinical review of submitted requests and clinical records
Apply approved medical necessity criteria to determine medical necessity and appropriateness of requested services
Interpret and apply InterQual criteria, CMS guidelines, Capital Blue Cross Medical Policies, CHIP handbook, FEP Medical Policies, FEP Benefit Brochure, and ASAM guidelines as applicable
Perform high-acuity utilization management case reviews within regulatory and departmental policy frameworks
Maintain member confidentiality and comply with internal and regulatory requirements
Collaborate with UM staff, Clinical Support Specialists, and Medical Directors to make final determinations
Collaborate with Care Management staff on discharge planning and transition-of-care activities
Participate in weekly clinical rounds for complex members
Identify and refer members with complex needs to population health and/or care management programs
Identify and refer members with Potential Quality Issues through established processes
Suggest departmental process improvements and identify learning and education opportunities
Attend and participate in company and departmental meetings and training sessions
Practice within the scope of clinical license and/or certification

Requirements

What you’ll need

Active, current, and unrestricted Registered Nurse licensure in Pennsylvania
Certified Case Manager (CCM) or Accredited Case Manager (ACM) certification, or ability to obtain within 2 years from date of hire
Minimum 5 years’ experience working in a higher level of care clinical role, including acute care hospital or post-acute care facility
1 year of utilization management experience in managed care
Working knowledge and operation of a personal computer
Proficiency in Microsoft Office applications
Knowledge of medical coding guidelines, including ICD-10-CM, CPT, and HCPCS codes
Working knowledge of NCQA, CMS, and other health plan utilization management regulations
Extensive knowledge of managed care principles and emerging health treatment modalities
Ability to critically think through processes, make clinically appropriate decisions, and solve problems
Ability to prioritize multiple clinical and administrative tasks and assignments
Ability to work independently and as part of a team
Ability to interact with departments to advise, educate, and/or direct members to clinical programs and services
Ability to communicate clearly and concisely in written and oral communications

Benefits

Comp & perks

Medical, Dental & Vision coverage
Retirement Plan
Paid Time Off
Holidays
Volunteer time off
Incentive Plan
Tuition Reimbursement
Flexible work environment
Training and continuing education
Professional and personal growth support
Community volunteering opportunities