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Utilization Management Nurse, Senior Leader
2 months ago
We 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 Responsibilities- Perform prospective, concurrent, and retrospective utilization reviews and first-level determination approvals for members using evidence-based guidelines, policies, and nationally recognized clinical criteria.
- Conduct clinical reviews 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, including levels of care, durable medical equipment, and post-service needs.
- Prepare and present cases to Medical Directors for medical director oversight and necessity determination, and communicate determinations to providers and/or members 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.
- 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.
- Maintain a HIPAA-compliant workspace for telework environments.
- Bachelor's of Science in Nursing or advanced degree preferred.
- Current California RN License required.
- At least 5 years of prior relevant experience required.
- Strong communication and computer navigation skills required.
- Strong teamwork and collaboration skills desired.
- Independent motivation and strong work ethic required.
- Strong critical thinking skills required.
The pay range for this role is competitive and based on a variety of factors, including the candidate's experience, location, and current employee salaries for similar roles.
