Senior Nurse for Utilization Management
2 weeks ago
Position Overview
The Utilization Management division is responsible for evaluating inpatient admissions for our members, adhering to established standards of care. The Senior Utilization Management Nurse will work under the supervision of the Utilization Management Nurse Manager. In this capacity, 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. Additionally, you will oversee discharge planning and facilitate transfers to ensure continuity of care.
Key Responsibilities
In this position, your duties will include:
- Conducting prospective utilization assessments and initial approval determinations for members based on evidence-based guidelines and recognized clinical criteria.
- Performing clinical evaluations of cases to ensure medical necessity, coding accuracy, and compliance with medical policies and contracts.
- Offering subject matter expertise and support to team members in conducting utilization management reviews to ensure appropriate member treatment based on medical necessity.
- Prioritizing and triaging cases to meet established turnaround times.
- Facilitating timely access to necessary care for members with urgent needs.
- Preparing and presenting cases to the Medical Director for oversight and necessity determinations, and communicating these determinations to providers and members in accordance with regulatory requirements.
- Creating and reviewing member-focused documentation and correspondence that reflects determinations in line with regulatory and accreditation standards.
- Identifying potential quality of care concerns, treatment delays, and implementing interventions when clinically appropriate.
- Providing referrals to Case Management, Disease Management, Appeals and Grievance, and Quality Departments as necessary.
- Participating in staff meetings, clinical rounds, and weekly team huddles.
- Maintaining quality and productivity metrics for all casework.
- Ensuring a HIPAA-compliant workspace in a telework environment.
Qualifications and Skills
- Bachelor of Science in Nursing or an advanced degree is preferred.
- A current California RN License is required.
- At least 5 years of relevant experience is necessary.
- Experience in a health plan setting is preferred.
- Prior authorization experience is advantageous.
- Strong written and verbal communication skills are essential.
- Excellent analytical and problem-solving abilities are required.
- Ability to work collaboratively within a team is important.
- Self-motivation and a strong work ethic are necessary attributes.
Compensation Information
The compensation range for this role is competitive and commensurate with experience.
Additional Information
This range reflects the compensation for this and similar positions within Blue Shield of California. Salaries are determined based on various factors, including the candidate's experience and current employee salaries for comparable roles.
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