Utilization Management Nurse Senior
6 days ago
About the Role:
The Utilization Management Nurse, Senior will play a critical role in ensuring that our members receive the most appropriate care possible. As a member of the Utilization Management team, you will be responsible for reviewing inpatient stays to determine medical necessity and ensuring that our members receive the highest quality care.
Key Responsibilities:
- Perform prospective utilization reviews and first-level determination approvals for members using evidence-based guidelines and nationally recognized clinical criteria.
- Conduct clinical reviews of cases for medical necessity, coding accuracy, medical policy compliance, and contract compliance.
- Provide subject matter expertise and support to team members, conducting UM review activities to ensure that member treatment meets appropriateness of care based on medical necessity criteria.
- Triage and prioritize cases to meet required turn-around times, expediting access to appropriate care for members with urgent needs.
- Prepare and present cases to the Medical Director for medical director oversight and necessity determination, communicating determinations to providers and/or members to comply with state, federal, and accreditation requirements.
- Develop and review member-centered documentation and correspondence reflecting determinations in compliance with regulatory and accreditation standards.
- Identify potential quality of care issues, service or treatment delays, and apply interventions when clinically appropriate.
- Provide referrals to Case Management, Disease Management, Appeals and Grievance, and Quality Departments as necessary.
- Attend staff meetings, clinical rounds, and weekly huddles, maintaining quality and productivity metrics for all casework.
- Maintain a HIPAA-compliant workspace for telework environments.
Requirements:
- Bachelor's of Science in Nursing or advanced degree preferred.
- Current California RN License required.
- At least 5 years of prior relevant experience required.
- Health plan experience preferred.
- Prior Authorization experience preferred.
- Strong written and oral communication skills required.
- Strong analytical and problem-solving skills required.
- Strong teamwork and collaboration skills required.
- Independent motivation and strong work ethic required.
Pay Range:
The pay range for this role is $87,230.00 to $130,900.00 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 (California, Bay area, or outside California), and current employee salaries for similar roles.
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