Utilization Management Nurse, Senior

4 weeks ago

Rancho Cordova, United States Blue Shield Of California Full time

Your 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, Senior 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 provided by the facilities to determine medical necessity when our members admit. You will also be involved with discharge planning and transfers as needed for higher levels of care or out of network admissions.

Your Work

In this role, you will:

  • Perform prospective, concurrent and retrospective utilization reviews and first level determination approvals for members using BSC evidenced based guidelines, policies and nationally recognized clinal criteria across lines of business or for a specific line of business such as Medicare and FEP
  • Conducts clinical review of claims for medical necessity, coding accuracy, medical policy compliance and contract compliance
  • 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 to ensure quality and cost-appropriate DC planning
  • 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 and identify potential quality of care issues, service or treatment delays and intervenes or as clinically appropriate
  • 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
  • Buddy or support new employees
  • 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
  • Requires strong communication and computer navigation skills
  • Desires strong teamwork and collaboration skills
  • Requires independent motivation and strong work ethic
  • Requires strong critical thinking skills

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.

#LI-RU1

  • Senior Nurse for Utilization Management

    2 weeks ago

    Rancho Cordova, California, United States Blue Shield of California Full time

    Position OverviewThe Utilization Management department is responsible for evaluating inpatient admissions for our members, adhering to established standards of care. The Senior Utilization Management Nurse will report directly to the Nurse Manager of Utilization Management. In this capacity, you will be assigned specific inpatient facilities and will assess...

  • Senior Nurse for Utilization Management

    1 week ago

    Rancho Cordova, California, United States Blue Shield of California Full time

    Your RoleThe Utilization Management division is responsible for evaluating inpatient admissions for our members, ensuring adherence to established guidelines for recognized standards of care.The Senior Utilization Management Nurse will report directly to the Nurse Manager of Utilization Management.In this capacity, you will be assigned a roster of inpatient...

  • Senior Nurse for Utilization Management

    1 week ago

    Rancho Cordova, California, United States Blue Shield of California Full time

    Position OverviewThe Utilization Management department is responsible for evaluating inpatient admissions for our members, adhering to established standards of care. The Senior Utilization Management Nurse will work under the guidance of the Utilization Management Nurse Manager. This role involves assessing clinical data from various inpatient facilities to...

  • Senior Nurse for Utilization Management

    2 weeks ago

    Rancho Cordova, California, United States Blue Shield of California Full time

    Position OverviewThe Utilization Management department is dedicated to evaluating inpatient admissions for our members, adhering to established standards of care. The Senior Utilization Management Nurse will report directly to the Nurse Manager of Utilization Management. In this capacity, you will be tasked with reviewing clinical data from assigned...

  • Senior Nurse for Utilization Management

    1 week ago

    Rancho Cordova, California, United States Blue Shield of California Full time

    Position OverviewThe Utilization Management department is responsible for evaluating inpatient admissions for our members, adhering to established national care standards. The Senior Utilization Management Nurse will report directly to the Nurse Manager of Utilization Management. In this capacity, you will be tasked with reviewing clinical data from various...

  • Senior Nurse for Utilization Management

    1 week ago

    Rancho Cordova, California, United States Blue Shield of California Full time

    Position OverviewThe Utilization Management division is responsible for evaluating inpatient admissions for our members, adhering to established standards of care. The Senior Utilization Management Nurse will work under the supervision of the Utilization Management Nurse Manager. This role involves reviewing clinical data from assigned inpatient facilities...

  • Senior Nurse for Utilization Management

    2 weeks ago

    Rancho Cordova, California, United States Blue Shield of California Full time

    Position OverviewThe Utilization Management division is responsible for evaluating inpatient admissions for our members, adhering to established standards of care. The Senior Utilization Management Nurse will work under the supervision of the Utilization Management Nurse Manager. In this capacity, you will be tasked with reviewing clinical data from various...

  • Senior Nurse for Utilization Management

    2 weeks ago

    Rancho Cordova, California, United States Blue Shield of California Full time

    Your RoleThe Utilization Management division evaluates inpatient admissions for our members in accordance with established national care standards. The Senior Utilization Management Nurse will report directly to the Utilization Management Nurse Manager. In this capacity, you will be assigned a roster of inpatient facilities and will assess clinical data...

  • Senior Nurse for Utilization Management

    2 weeks ago

    Rancho Cordova, California, United States Blue Shield Of California Full time

    Position OverviewThe Senior Utilization Management Nurse plays a crucial role in overseeing inpatient admissions for our members, ensuring compliance with established care standards.Key ResponsibilitiesIn this position, you will be tasked with reviewing clinical data from various inpatient facilities to assess the medical necessity of admissions, appropriate...

  • Utilization Management Nurse, Senior

    3 weeks ago

    Rancho Cordova, United States Blue Shield of California Full time

    Your 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, Senior will report to the Utilization Management Nurse Manager. In this role you will be assigned a list of inpatient facilities and then review clinical...

  • Utilization Management Nurse, Senior

    3 weeks ago

    Rancho Cordova, United States Blue Shield of California Full time

    Your 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, Senior will report to the Utilization Management Nurse Manager. In this role you will be assigned a list of inpatient facilities and then review clinical...

  • Utilization Management Nurse, Senior

    1 month ago

    Rancho Cordova, United States Blue Shield of California Full time

    Your 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, Senior will report to the Utilization Management Nurse Manager. In this role you will be assigned a list of inpatient facilities and then review clinical...

  • Utilization Management Nurse, Senior

    3 weeks ago

    Rancho Cordova, United States Blue Shield of CA Full time

    Your 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, Senior will report to the Utilization Management Nurse Manager. In this role you will be assigned a list of inpatient facilities and then review clinical...

  • Utilization Management Nurse, Senior Leader

    1 week ago

    Rancho Cordova, California, United States Blue Shield of California Full time

    About the RoleWe are seeking a highly skilled Utilization Management Nurse, Senior to join our team at Blue Shield of California. As a key member of our Utilization Management team, you will play a critical role in ensuring our members receive the highest quality care while maintaining cost-effectiveness.Your Key ResponsibilitiesPerform prospective,...

  • Utilization Management Nurse, Senior

    4 days ago

    Rancho Cordova, United States Blue Shield of California Full time

    Your 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...

  • Utilization Management Nurse, Senior

    3 days ago

    Rancho Cordova, United States Blue Shield Of California Full time

    Your 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...

  • Utilization Management Nurse, Senior

    4 days ago

    Rancho Cordova, United States Blue Shield of California Full time

    Your 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...

  • Utilization Management Nurse, Senior

    3 days ago

    Rancho Cordova, United States Blue Shield of California Full time

    Your 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...

  • Utilization Management Nurse, Senior

    4 weeks ago

    Rancho Cordova, United States Blue Shield Of California Full time

    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...

  • Utilization Management Nurse, Senior

    3 days ago

    Rancho Cordova, California, United States Blue Shield Of California Full time

    About the RoleThe Utilization Management Nurse, Senior will play a critical role in ensuring the quality and cost-effectiveness of healthcare services for our members. As a seasoned healthcare professional, you will be responsible for reviewing inpatient stays to determine medical necessity, appropriate length of stay, and level of care.Key...