Utilization Management Nurse Senior
1 week ago
As a key member of the Utilization Management team at Blue Shield of California, you will play a critical role in ensuring our members receive the most appropriate and cost-effective care.
Reporting to the Utilization Management Nurse Manager, you will be responsible for reviewing inpatient stays for our members and applying nationally recognized levels of care guidelines. Your expertise will be essential in determining medical necessity and ensuring that our members receive the highest quality care.
Your Work- Conduct prospective, concurrent, and retrospective utilization reviews to determine medical necessity and ensure compliance with BSC evidenced-based guidelines and nationally recognized clinical criteria.
- Review claims for medical necessity, coding accuracy, medical policy compliance, and contract compliance.
- Develop and implement discharge planning strategies to ensure members receive the most appropriate level of care.
- Prepare and present cases to the Medical Director for oversight and determination.
- Communicate determinations to providers and members in compliance with state, federal, and accreditation requirements.
- Collaborate with Case Management to address acute inpatient needs affecting discharge.
- Attend staff meetings, clinical rounds, and weekly huddles to stay informed and aligned with team goals.
- Maintain quality and productivity metrics for all casework.
- Support new employees and maintain a HIPAA-compliant workspace for telework.
- Bachelor's degree in Nursing or advanced degree preferred.
- Current California RN License required.
- At least 5 years of prior relevant experience.
- Strong communication and computer navigation skills.
- Desirable teamwork and collaboration skills.
- Independent motivation and strong work ethic.
- Strong critical thinking skills.
Pay Range: The pay range for this role is $ to $ for California.
Note: 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, and current employee salaries for similar roles.
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