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Senior Nurse for Utilization Management
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Position Overview
The Senior Utilization Management Nurse plays a crucial role in overseeing inpatient admissions for our members, ensuring compliance with established care standards.
Key Responsibilities
In this position, you will be tasked with reviewing clinical data from various inpatient facilities to assess the medical necessity of admissions, appropriate duration of stay, and required level of care.
Your responsibilities will include:
- Conducting concurrent utilization assessments and initial approval determinations for members, utilizing evidence-based guidelines and nationally recognized clinical criteria.
- Performing clinical evaluations to ensure medical necessity, coding accuracy, and adherence to medical policies and contractual obligations.
- Providing subject matter expertise and support to team members.
- Facilitating utilization management reviews to ensure appropriate treatment aligns with recommended lengths of stay based on medical necessity.
- Coordinating discharge planning to meet the needs of members, including post-acute care requirements and necessary medical equipment.
- Prioritizing cases to adhere to turnaround time requirements and expediting access to urgent care when necessary.
- Preparing and presenting cases to the Medical Director for oversight and necessity determinations, ensuring compliance with regulatory standards.
- Developing member-centered documentation that reflects determinations in line with accreditation standards.
- Identifying potential quality of care concerns and implementing interventions as clinically appropriate.
- Referring cases to Case Management, Disease Management, and Quality Departments as needed.
- Participating in staff meetings and maintaining productivity metrics for all casework.
Qualifications
To be successful in this role, candidates should possess:
- A Bachelor of Science in Nursing or an advanced degree is preferred.
- A current RN License in California.
- A minimum of 5 years of relevant experience, preferably in a health plan setting.
- Experience in concurrent review is advantageous.
- Strong written and verbal communication skills.
- Excellent analytical and problem-solving abilities.
- A collaborative mindset and the ability to work independently.
Compensation
The compensation for this role will be determined based on experience and qualifications.
About Blue Shield of California
Blue Shield of California is committed to providing high-quality healthcare access at an affordable price. We are dedicated to fostering a diverse and inclusive environment where all employees can thrive and contribute to our mission of improving healthcare for all Californians.
Our Values
We uphold the highest standards of ethics and integrity, strive for authenticity in our interactions, and demonstrate courage in our commitments.
Work Environment
We offer a flexible work model, allowing employees to choose between hybrid and office-based work arrangements, ensuring a balance between professional and personal life.
