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Senior Nurse for Utilization Management
2 months ago
Your Role
The Utilization Management division is responsible for evaluating inpatient admissions for our members, ensuring adherence to established guidelines for recognized 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 a roster of inpatient facilities and tasked with reviewing clinical data provided by these facilities to assess medical necessity for member admissions.
Your Responsibilities
In this position, you will:
- Conduct prospective, concurrent, and retrospective utilization assessments and initial determination approvals for members utilizing BSC evidence-based guidelines, policies, and nationally recognized clinical criteria across various lines of business, including Medicare and FEP.
- Perform clinical evaluations of claims to ensure medical necessity, coding accuracy, compliance with medical policies, and adherence to contractual obligations.
- Facilitate discharge planning that aligns with the members' needs and acuity, determining post-acute requirements such as levels of care, durable medical equipment, and other post-service necessities to ensure effective and cost-efficient discharge planning.
- Prepare and present cases to the Medical Director for oversight and necessity evaluation, communicating decisions to providers and/or members in accordance with state, federal, and accreditation standards.
- Develop and review member-focused documentation and correspondence that reflects determinations in compliance with regulatory and accreditation standards, identifying potential quality of care concerns, service delays, or treatment interruptions, and intervening as clinically appropriate.
- Refer cases to Case Management when acute inpatient needs impact discharge.
- Participate in staff meetings, clinical rounds, and weekly huddles.
- Maintain quality and productivity metrics for all casework.
- Provide support and mentorship to new employees.
- Ensure a HIPAA-compliant workspace in a telework environment.
Your Qualifications
Bachelor of Science in Nursing or an advanced degree is preferred. A current California RN License is required, along with a minimum of 5 years of relevant experience. Strong communication and computer navigation skills are essential, as well as a desire for teamwork and collaboration. Independent motivation, a robust work ethic, and strong critical thinking abilities are necessary.
Pay Range:
The compensation range for this position is competitive and reflective of the market standards.
Note:
Please be aware that this range is indicative of the pay scale for this and other roles within Blue Shield that fall under the same pay grade. Salaries are determined based on various factors, including the candidate's experience and current employee salaries for similar positions.
