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Senior Utilization Management Nurse
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Senior Utilization Management Nurse
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Senior Utilization Management Nurse
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Rancho Cordova, California, United States Blue Shield Of California Full timeJob SummaryThe Senior Utilization Management Nurse will be responsible for reviewing inpatient stays for our members under nationally recognized levels of care guidelines. This role requires a strong clinical background and excellent analytical skills to determine medical necessity of admissions, appropriate length of stay, and level of care.Key...
Clinical Utilization Manager
2 months ago
We are seeking a skilled Vocational Nurse to join our team as a Clinical Utilization Manager in our Outpatient UM department. As a key member of our team, you will play a critical role in ensuring the efficient and effective management of outpatient services and care.
Key Responsibilities- Gather and review clinical documentation to support the R.N. Letter Review Nurse and Medical Director in making informed decisions regarding outpatient services and care.
- Collaborate with the UM clinical team to ensure timely and compliant authorization of outpatient services, including surgery, durable medical equipment, and home health.
- Provide expert guidance to Member and Provider Service departments on outpatient utilization management, referral, and continuity of care issues.
- Identify gaps in provider network and work with the Contracts Department to address these gaps.
- Assist with the letter of agreement process for out-of-network provider referrals.
- Ensure timely and accurate documentation in the medical management system.
- Identify potential cases for Case Management, Disease Management, Health Education, and quality of care issues, and make referrals as needed.
- Explore alternate payer sources such as CCS and IRC.
- Support department goals and the vision of the organization through collaboration with team members.
- 2+ years of utilization management experience in a healthcare delivery setting.
- Experience in an HMO or managed care setting preferred.
- Active, unrestricted, and unencumbered LVN license issued by the California Board of Vocational Nursing and Psychiatric Technicians required.
- Driver's license required.
- Knowledge of Title 22, Title 10, DMHC, DHCS, and CMS regulatory requirements, ICD-9/10 and CPT coding, and capitated managed care environment helpful.
