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Utilization Management Nurse, Senior
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Rancho Cordova, United States Blue Shield Of California Full timeYour Role The Utilization Management team reviews the inpatient stays for our members and correctly applies the guidelines for nationally recognized levels of care. The Utilization Management Nurse will report to the Utilization Management Nurse Manager. In this role you will be assigned a list of inpatient facilities and then review clinical information...
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Rancho Cordova, United States Blue Shield of California Full timeYour Role The Utilization Management team reviews the inpatient stays for our members and correctly applies the guidelines for nationally recognized levels of care. The Utilization Management Nurse will report to the Utilization Management Nurse Manager. In this role you will be assigned a list of inpatient facilities and then review clinical information...
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Utilization Management Nurse, Senior
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Rancho Cordova, United States Blue Shield of California Full timeYour Role The Utilization Management team reviews the inpatient stays for our members under the guidelines for nationally recognized levels of care. The Utilization Management Nurse, Senior will report to the Utilization Management Nurse Manager. In this role you will be assigned a list of inpatient facilities and review clinical information provided by the...
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Utilization Management Nurse, Senior
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Rancho Cordova, United States Blue Shield of California Full timeUtilization Management Nurse, Senior (Prior Authorization - CalPERS) at Blue Shield of California summary: The Senior Utilization Management Nurse conducts clinical reviews to assess the medical necessity of inpatient admissions and length of stay, ensuring compliance with regulations. This role involves collaborating with healthcare teams, preparing...
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Rancho Cordova, California, United States Blue Shield of California Full timeAbout the RoleWe are seeking a seasoned healthcare professional to lead our Utilization Management team at Blue Shield of California. As Senior Healthcare Manager, Utilization Excellence, you will play a critical role in ensuring our members receive timely and cost-effective care.Key ResponsibilitiesStrategic Leadership: Develop and implement utilization...
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Utilization Management Nurse, Senior
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Rancho Cordova, United States Blue Shield Of California Full timeYour Role The Utilization Management team reviews the inpatient stays for our members and correctly applies the guidelines for nationally recognized levels of care. The Utilization Management Nurse will report to the Utilization Management Nurse Manager. In this role you will be assigned a list of inpatient facilities and then review clinical information...
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Utilization Management Nurse, Senior
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Rancho Cordova, United States Blue Shield of California Full timeYour Role The Utilization Management team reviews the inpatient stays for our members and correctly applies the guidelines for nationally recognized levels of care. The Utilization Management Nurse will report to the Utilization Management Nurse Manager. In this role you will be assigned a list of inpatient facilities and then review clinical information...
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Utilization Management Nurse, Senior
2 months ago
Rancho Cordova, United States Blue Shield of California Full timeYour RoleThe Utilization Management team reviews the inpatient stays for our members and correctly applies the guidelines for nationally recognized levels of care. The Utilization Management Nurse will report to the Utilization Management Nurse Manager. In this role you will be assigned a list of inpatient facilities and then review clinical information...
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Utilization Management Nurse, Senior
2 months ago
Rancho Cordova, United States Blue Shield of California Full timeYour Role The Utilization Management team reviews the inpatient stays for our members and correctly applies the guidelines for nationally recognized levels of care. The Utilization Management Nurse will report to the Utilization Management Nurse Manager. In this role you will be assigned a list of inpatient facilities and then review clinical information...
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Utilization Management Nurse, Senior
2 weeks ago
Rancho Cordova, United States Blue Shield of California Full timeYour Role The Utilization Management team reviews the inpatient stays for our members and correctly applies the guidelines for nationally recognized levels of care. The Utilization Management Nurse will report to the Utilization Management Nurse Manager. In this role you will be assigned a list of inpatient facilities and then review clinical information...
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Utilization Management Nurse, Senior
2 weeks ago
Rancho Cordova, United States Blue Shield of California Full timeYour Role The Utilization Management team reviews the inpatient stays for our members and correctly applies the guidelines for nationally recognized levels of care. The Utilization Management Nurse will report to the Utilization Management Nurse Manager. In this role you will be assigned a list of inpatient facilities and then review clinical information...
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Utilization Management Nurse, Senior
3 months ago
Rancho Cordova, United States Blue Shield of California Full timeYour Role The Utilization Management team reviews the inpatient stays for our members and correctly applies the guidelines for nationally recognized levels of care. The Utilization Management Nurse will report to the Utilization Management Nurse Manager. In this role you will be assigned a list of inpatient facilities and then review clinical information...
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Utilization Management Nurse, Senior
2 months ago
Rancho Cordova, United States Blue Shield of California Full timeYour Role The Utilization Management team reviews the inpatient stays for our members and correctly applies the guidelines for nationally recognized levels of care. The Utilization Management Nurse will report to the Utilization Management Nurse Manager. In this role you will be assigned a list of inpatient facilities and then review clinical information...
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Utilization Management Nurse, Senior
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Rancho Cordova, United States Blue Shield Of California Full timeYour Role The Utilization Management team reviews the inpatient stays for our members and correctly applies the guidelines for nationally recognized levels of care. The Utilization Management Nurse will report to the Utilization Management Nurse Manager. In this role you will be assigned a list of inpatient facilities and then review clinical information...
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Utilization Management Nurse, Senior
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Rancho Cordova, United States Blue Shield of California Full timeYour RoleLearn more about the general tasks related to this opportunity below, as well as required skills.The Utilization Management team reviews the inpatient stays for our members and correctly applies the guidelines for nationally recognized levels of care. The Utilization Management Nurse will report to the Utilization Management Nurse Manager. In this...
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Utilization Management Nurse, Senior
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Rancho Cordova, United States Blue Shield of California Full timeYour RoleThe Utilization Management Prior Authorization team processes accurate and timely prior authorization of designated healthcare services, continuity or care, and access to care clinical review determinations. The Utilization Management Nurse, Senior will report to the Manager, Utilization and Medical Review. In this role you will be performing first...
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Utilization Management Nurse, Senior
4 weeks ago
Rancho Cordova, United States Blue Shield of CA Full timeYour Role The Utilization Management Prior Authorization team processes accurate and timely prior authorization of designated healthcare services, continuity or care, and access to care clinical review determinations. The Utilization Management Nurse, Senior will report to the Manager, Utilization and Medical Review. In this role you will be performing first...
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Utilization Management Nurse, Senior
2 months ago
Rancho Cordova, United States Blue Shield of California Full timeYour Role The Utilization Management Prior Authorization team processes accurate and timely prior authorization of designated healthcare services, continuity or care, and access to care clinical review determinations. The Utilization Management Nurse, Senior will report to the Manager, Utilization and Medical Review. In this role you will be performing first...
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Rancho Cordova, California, United States Blue Shield of California Full timeJob SummaryIn this challenging and rewarding role as a Senior Utilization Management Nurse at Blue Shield of California, you will be responsible for reviewing inpatient stays to ensure medical necessity in compliance with state and federal regulations. Your expertise in clinical review, discharge planning, and presenting cases to the Medical Director will...
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Utilization Management Nurse, Senior
3 months ago
Rancho Cordova, United States Blue Shield of CA Full timeYour Role The Utilization Management team reviews the inpatient stays for our members under the guidelines for nationally recognized levels of care. The Utilization Management Nurse, Senior will report to the Utilization Management Nurse Manager. In this role you will be assigned a list of inpatient facilities and review clinical information provided by the...
Utilization Management Nurse, Senior
2 months ago
Your Role
The Utilization Management team reviews the inpatient stays for our members under the guidelines for nationally recognized levels of care. The Utilization Management Nurse, Senior will report to the Utilization Management Nurse Manager. In this role you will be assigned a list of inpatient facilities and review clinical information provided by the facilities to determine medical necessity of admissions, appropriate length of stay and level of care. You will also be responsible for discharge planning and transfers as needed for next appropriate levels of care, or out of network admissions.
Your Work
In this role, you will:
- Perform prospective utilization reviews and first level determination approvals for members using BSC evidenced based guidelines, policies and nationally recognized clinal criteria
- Conducts clinical review of cases for medical necessity, coding accuracy, medical policy compliance and contract compliance
- Provides SME and support to team members Conduct UM review activities for appropriate member treatment to meet appropriateness of care based on medical necessity criteria
- Triages and prioritizes cases to meet required turn-around times
- Expedites access to appropriate care for members with urgent needs
- Prepare and present cases to Medical Director (MD) for medical director oversight and necessity determination and communicate determinations to providers and/or members to in compliance with state, federal and accreditation requirements
- Develop and review member centered documentation and correspondence reflecting determinations in compliance with regulatory and accreditation standards
- Identify potential quality of care issues, service or treatment delays, and apply interventions when clinically appropriate
- Provides referrals to Case Management, Disease Management, Appeals and Grievance, and Quality Departments as necessary
- Attend staff meetings, clinical rounds and weekly huddles
- Maintain quality and productivity metrics for all casework
- Maintaining HIPAA compliant workspace for telework environment
Your Knowledge and Experience
- Bachelors of Science in Nursing or advanced degree preferred
- Requires a current California RN License
- Requires at least 5 years of prior relevant experience
- Health plan experience preferred
- Prior Authorization experience preferred
- Requires strong written and oral communication skills
- Strong analytical and problem-solving skills
- Strong teamwork and collaboration skills
- Requires independent motivation and strong work ethic
Pay Range:
The pay range for this role is: $ 87230.00 to $ 130900.00 for California.
Note:
Please note that this range represents the pay range for this and many other positions at Blue Shield that fall into this pay grade. Blue Shield salaries are based on a variety of factors, including the candidate's experience, location (California, Bay area, or outside California), and current employee salaries for similar roles.
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