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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 concurrent 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 Recommended Length of Stay based on medical necessity criteria.
- Ensure discharge (DC) planning at levels of care appropriate for the members needs and acuity and determine post-acute needs of member including levels of care, durable medical equipment, and post service needs, ensuring quality and cost-appropriate DC planning.
- 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.
- Refer to Case Management when there are acute inpatient needs affecting discharge.
- 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
- Concurrent review 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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