Senior Nurse for Utilization Management
2 weeks ago
The Utilization Management division evaluates inpatient admissions for our members in accordance with established national care standards.
In this capacity, you will be assigned a roster of inpatient facilities and will assess clinical data provided by these facilities to ascertain the medical necessity of admissions, appropriate duration of stay, and level of care required.
Your responsibilities will also include discharge planning and facilitating transfers as necessary to ensure appropriate subsequent levels of care or manage out-of-network admissions.
In this position, you will:
Conduct concurrent utilization assessments and initial determination approvals for members utilizing BSC evidence-based guidelines, policies, and nationally recognized clinical criteria.
Provide subject matter expertise and support to team members. Conduct UM review activities to ensure appropriate member treatment aligns with recommended lengths of stay based on medical necessity criteria.
Facilitate discharge planning at levels of care that are suitable for the member's needs and acuity, while also determining post-acute requirements, including levels of care, durable medical equipment, and other post-service necessities, ensuring quality and cost-effective discharge planning.
Accelerate access to necessary care for members with urgent requirements.
Prepare and present cases to the Medical Director for oversight and necessity determinations, and communicate these determinations to providers and/or members in compliance with state, federal, and accreditation standards.
Identify potential quality of care concerns, service delays, or treatment delays, and implement interventions when clinically appropriate.
Provide referrals to Case Management, Disease Management, Appeals and Grievance, and Quality Departments as needed.
Refer 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.
Ensure a HIPAA-compliant workspace in a telework environment.
Your Knowledge and Experience
Bachelor of Science in Nursing or an advanced degree is preferred.
A current California RN License is required.
A minimum of 5 years of relevant experience is necessary.
Experience in a health plan setting is preferred.
Concurrent review experience is advantageous.
Strong written and verbal communication skills are essential.
Excellent analytical and problem-solving abilities are required.
Strong teamwork and collaboration skills are vital.
Independent motivation and a robust work ethic are necessary.
Pay Range:
The pay range for this role is: $ to $ for California.
Note:
This range represents the pay scale for this and many other positions at Blue Shield that fall within this pay grade.
Blue Shield salaries are determined by various factors, including the candidate's experience, location (California, Bay area, or outside California), and current employee salaries for similar roles.
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