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Healthcare Utilization Specialist

2 months ago

Oakland, California, United States Blue Shield of California Full time

Job Summary:

The Utilization Management team at Blue Shield of California reviews inpatient stays for our members and applies nationally recognized levels of care guidelines. As a Utilization Management Nurse, Senior, you will report to the Utilization Management Nurse Manager and be responsible for reviewing clinical information provided by facilities to determine medical necessity for our members' admissions. This role involves discharge planning and transfers as needed for higher levels of care or out-of-network admissions.

Key Responsibilities:

  • Perform prospective, concurrent, and retrospective utilization reviews and first-level determination approvals for members using Blue Shield of California's evidenced-based guidelines, policies, and nationally recognized clinical criteria across lines of business or for a specific line of business, such as Medicare and FEP.
  • Conduct clinical review of claims for medical necessity, coding accuracy, medical policy compliance, and contract compliance.
  • Ensure discharge planning at levels of care appropriate for members' needs and acuity, and determine post-acute needs of members, including levels of care, durable medical equipment, and post-service needs to ensure quality and cost-appropriate discharge planning.
  • Prepare and present cases to Medical Director for medical director oversight and necessity determination and communicate determinations to providers and/or members to be 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 intervene as clinically appropriate.
  • Attend staff meetings, clinical rounds, and weekly huddles.
  • Maintain quality and productivity metrics for all casework.
  • Maintain HIPAA-compliant workspace for telework environment.

Requirements:

  • Bachelor of Science in Nursing or advanced degree preferred.
  • Strong communication and computer navigation skills preferred.