Senior Nurse for Utilization Management
2 weeks ago
Position Overview
The 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 clinical data provided by these facilities to ascertain the medical necessity of admissions, appropriate duration of stay, and required level of care.
Key Responsibilities
In this position, your duties will include:
- Conducting prospective utilization assessments and initial approval determinations for members utilizing evidence-based guidelines, policies, and nationally recognized clinical criteria.
- Performing clinical evaluations of cases to ensure medical necessity, coding accuracy, and compliance with medical policies and contracts.
- Offering subject matter expertise and support to team members while conducting utilization management reviews to ensure appropriate member treatment aligns with medical necessity standards.
- Prioritizing and triaging cases to meet established turnaround times.
- Facilitating expedited access to necessary care for members with urgent requirements.
- Preparing and presenting cases to the Medical Director for oversight and necessity evaluations, and communicating decisions to providers and/or members in accordance with regulatory and accreditation standards.
- Creating and reviewing member-focused documentation and correspondence that reflects determinations in compliance with regulatory and accreditation guidelines.
- Identifying potential quality of care concerns, service delays, and implementing interventions when clinically appropriate.
- Providing referrals to Case Management, Disease Management, Appeals and Grievance, and Quality Departments as necessary.
- Participating in staff meetings, clinical rounds, and weekly huddles.
- Maintaining quality and productivity metrics for all casework.
- Ensuring a HIPAA-compliant workspace in a telework environment.
Qualifications and Experience
- Bachelor of Science in Nursing or an advanced degree is preferred.
- A current California RN License is required.
- At least 5 years of relevant experience is necessary.
- Experience in a health plan setting is preferred.
- Prior authorization experience is advantageous.
- Strong written and verbal communication skills are essential.
- Analytical and problem-solving abilities are crucial.
- Teamwork and collaboration skills are required.
- Independent motivation and a strong work ethic are necessary.
Compensation Information
The compensation range for this position is competitive and reflects the experience and qualifications of the candidate.
Note:
This range represents the compensation for this and various other roles at Blue Shield of California that fall within this pay grade. Salaries are determined based on multiple factors, including the candidate's experience and location.
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