Utilization Management Nurse Senior
6 days ago
We are seeking a highly skilled Utilization Management Nurse, Senior to join our team at Blue Shield of CA. As a key member of our Utilization Management team, you will play a critical role in reviewing inpatient stays for our members and ensuring that nationally recognized levels of care are applied correctly.
Key Responsibilities- Perform prospective, concurrent, and retrospective utilization reviews and first-level determination approvals for members using BSC evidenced-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 the member's 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 (MD) 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 environment.
- Bachelor's 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.
The pay range for this role is: $ to $ for California.
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.
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