Senior Utilization Management Nurse
5 days ago
Your Role
The Utilization Management team reviews inpatient stays for our members under nationally recognized levels of care guidelines.
This role reports to the Utilization Management Nurse Manager.
As a Senior Utilization Management Nurse, you will be assigned a list of inpatient facilities and review clinical information provided by the facilities to determine medical necessity of admissions, appropriate length of stay, and level of care.
You will also be responsible for discharge planning and transfers as needed for next appropriate levels of care or out-of-network admissions.
Your Work
In this role, you will:
- Perform prospective utilization reviews and first-level determination approvals for members using BSC evidenced-based guidelines, policies, and nationally recognized clinical criteria.
- Conduct clinical reviews of cases for medical necessity, coding accuracy, medical policy compliance, and contract compliance.
- Provide SME and support to team members.
- Conduct UM review activities for appropriate member treatment to meet appropriateness of care based on medical necessity criteria.
- Triage and prioritize cases to meet required turn-around times.
- Expedite access to appropriate care for members with urgent needs.
- Prepare and present cases to Medical Director (MD) for medical director oversight and necessity determination and communicate determinations to providers and/or members in compliance 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.
- Maintain quality and productivity metrics for all casework.
- Maintain a HIPAA-compliant workspace for a telework environment.
Your Knowledge and Experience
Bachelor's of Science in Nursing or advanced degree preferred.
Requires a current California RN License.
Requires at least 5 years of prior relevant experience.
Health plan experience preferred.
Prior Authorization experience preferred.
Requires strong written and oral communication skills.
Strong analytical and problem-solving skills.
Strong teamwork and collaboration skills.
Requires independent motivation and a strong work ethic.
Pay Range:
The pay range for this role is: $ to $ for California.
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.
-
Senior Software Engineer, Keeper Secrets Manager
21 hours ago
El Dorado Hills, California, United States Keeper Security, Inc. Full timeAbout the RoleWe are seeking a highly motivated and experienced Senior Software Engineer to join our Keeper Dev team. This individual will play a pivotal role in designing, developing, and maintaining one of our core products, Keeper Secrets Manager.The successful candidate will have a strong background in full-stack software development, with experience in...
-
Senior Product Manager
2 weeks ago
El Dorado Hills, California, United States Keeper Security Full time### Job Title: Senior Product Manager, Privilege Manager ### About Keeper Security Keeper Security is a leading provider of cybersecurity software, trusted by millions of people and thousands of organizations globally. Our solutions are built on a foundation of zero-trust and zero-knowledge security to protect every user on every device. ### Job...
-
Senior Product Manager, Privilege Manager
2 weeks ago
El Dorado Hills, California, United States Keeper Security, Inc. Full timeJob Title: Senior Product Manager, Privilege ManagerKeeper Security is seeking an experienced Senior Product Manager to lead the development of our Privilege Manager product strategy. This role will be responsible for defining and driving the product roadmap, collaborating with cross-functional teams, and ensuring the successful delivery of new features and...
-
Senior Program Manager
4 days ago
El Dorado Hills, California, United States Blue Shield of CA Full timeYour RoleThe MCS Post Service Team at Blue Shield of CA oversees and manages vendor relationships to provide high-quality care and services. As a Senior Program Manager, you will report to the Program and Project Senior Manager. In this role, you will provide compliance oversight, updates, and contract adherence while partnering with cross-functional...
-
Senior Program Manager
4 days ago
El Dorado Hills, California, United States Blue Shield of CA Full timeJob SummaryThe Senior Program Manager will oversee and manage specific vendor relationships focused on providing high-quality care and services that support different areas of the business. This role reports to the Program and Project Senior Manager.Key ResponsibilitiesProvide overall program leadership, guidance, and manage all aspects of a given program,...
-
Medication Assistant
5 days ago
El Dorado Hills, California, United States Oakmont Senior Living Full timeJob Summary:The Medication Technician is responsible for supervising and assisting in the administration of medications to residents as ordered and in accordance with established nursing standards, policies, procedures, and practices of the company.Key Responsibilities: Prepare and distribute medication to residents. Coordinate medication services with the...
-
Senior Product Manager
4 days ago
El Dorado Hills, California, United States Keeper Security Full timeAbout the RoleKeeper Security is seeking an experienced Senior Product Manager to lead the development of our enterprise solutions, including Privileged Access Management. This is a 100% remote position.About KeeperKeeper Security is transforming cybersecurity for people and organizations around the world. Our award-winning, zero-trust, privileged access...
-
Senior Software Engineer, Keeper Secrets Manager
2 weeks ago
El Dorado Hills, California, United States Keeper Security, Inc. Full timeAbout the RoleWe are seeking a highly motivated and experienced Senior Software Engineer to join our Keeper Secrets Manager team. This is a 100% remote position with an opportunity to work a hybrid schedule for candidates based in the El Dorado Hills, CA or Chicago, IL metro area.Keeper's cybersecurity software is trusted by millions of people and thousands...
-
Senior Product Manager
4 weeks ago
El Dorado Hills, California, United States Keeper Security Full timeAbout Keeper SecurityKeeper Security is a leading provider of cybersecurity software, trusted by millions of people and thousands of organizations worldwide. Our award-winning solutions are built on a foundation of zero-trust and zero-knowledge security, protecting every user on every device.Job DescriptionWe are seeking an experienced Senior Product Manager...
-
Senior Product Manager, Privilege Manager
1 month ago
El Dorado Hills, California, United States Keeper Security, Inc. Full timeAbout the RoleWe are seeking an experienced Senior Product Manager to lead the development of our Privilege Manager product. As a key member of our team, you will be responsible for defining and driving the product strategy, collaborating with cross-functional teams, and ensuring the successful delivery of new features and products.Key...
-
Senior Estimator
1 month ago
El Dorado Hills, California, United States Roebbelen Contracting Full timeSenior EstimatorWe are seeking a highly skilled Senior Estimator to join our Estimating and Preconstruction team in El Dorado Hills. As a Senior Estimator, you will be responsible for accuracy, integrity, and completion of estimates at various phases, including design, conceptual, preconstruction, procurement, and construction phases.Key...
-
Senior Software Engineer
1 month ago
El Dorado Hills, California, United States Keeper Security, Inc. Full timeAbout the RoleWe are seeking a highly skilled Senior Software Engineer to join our Keeper Dev team. As a key member of our team, you will play a pivotal role in designing, developing, and maintaining our core product, Keeper Secrets Manager.As a Senior Software Engineer, you will collaborate with cross-functional teams to deliver high-quality software...
-
Program Manager Senior
4 weeks ago
El Dorado Hills, California, United States Blue Shield of CA Full timeYour RoleThe Strategic Planning and Performance team at Blue Shield of CA supports the Core and Small Group Sales organization, managing group business up to 2,999 members. As a Program Manager Senior - Core and Small Group, you will report to the Director of the Strategic Planning and Performance team. In this role, you will work cross-functionally to...
-
Senior Backend Software Engineer
1 month ago
El Dorado Hills, California, United States Keeper Security, Inc. Full timeJob Title: Senior Backend Software EngineerWe are seeking a highly skilled Senior Backend Software Engineer to join our Keeper development team. As a key member of our team, you will be responsible for designing, developing, and maintaining the core backend systems that power our applications.About the RoleAs a Senior Backend Software Engineer, you will work...
-
Senior Estimator
4 days ago
El Dorado Hills, California, United States Roebbelen Contracting Full timeSenior Estimator Job DescriptionWe are seeking a highly skilled Senior Estimator to join our Estimating and Preconstruction team in El Dorado Hills. As a Senior Estimator, you will be responsible for accuracy, integrity, and completion of estimates at various phases, including design, conceptual, preconstruction, procurement, and construction phases.Key...
-
Senior Windows Software Engineer
4 weeks ago
El Dorado Hills, California, United States Keeper Security Full time{"title": "Senior Windows Engineer Role", "description": "About the RoleWe are seeking a highly skilled Senior Windows Engineer to join our Keeper Dev team. As a key member of our team, you will play a pivotal role in designing, developing, and maintaining our Privileged Access Management platform for end-user devices using C++ or Rust technology along with...
-
Care Manager
7 days ago
El Dorado Hills, California, United States Blue Shield of California Full timeYour RoleAt Blue Shield of California, we are seeking a highly skilled Care Manager to join our team. The Care Manager will play a critical role in supporting the mission of our department, which is to provide exceptional care to our patients in the outpatient setting.The Senior Care Manager will report to the Manager of Care Management and will be...
-
Senior Estimator
5 days ago
El Dorado Hills, California, United States Roebbelen Contracting Full timeWe are seeking a skilled Senior Estimator to join our Estimating and Preconstruction team in El Dorado Hills. As a key member of our team, you will be responsible for accuracy, integrity, and completion of estimates at various phases, including design, conceptual, preconstruction, procurement, and construction phases.Key responsibilities include reviewing...
-
Senior Product Manager, Privilege Access Expert
2 weeks ago
El Dorado Hills, California, United States Keeper Security Full timeAbout Keeper SecurityKeeper Security is a leading provider of cybersecurity software, trusted by millions of people and thousands of organizations globally. Our solutions are built on a foundation of zero-trust and zero-knowledge security, protecting every user on every device.About the JobThe Senior Product Manager, Privilege Manager will collaborate with...
-
Medication Assistant
4 weeks ago
El Dorado Hills, California, United States Oakmont Senior Living Full timeMedication Technician Job DescriptionOakmont Senior Living is seeking a skilled Medication Technician to join our team. As a Medication Technician, you will play a vital role in ensuring the health and well-being of our residents by supervising and assisting in the administration of medications.Responsibilities:Prepare and distribute medication to residents...
