Utilization Management Nurse Senior
2 days ago
We are seeking a highly skilled Utilization Management Nurse, Senior to join our team at Blue Shield of California. As a key member of our Utilization Management team, you will play a critical role in ensuring our members receive high-quality, cost-effective care.
Key Responsibilities- Perform prospective utilization reviews and first-level determination approvals for members using evidence-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 subject matter expertise and support to team members, conducting 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, 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 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, maintaining quality and productivity metrics for all casework.
- Maintain a HIPAA-compliant workspace for telework environments.
- 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.
Blue Shield of California is a nonprofit health plan dedicated to making a positive impact on the health and well-being of our members and the communities we serve. We are committed to transforming healthcare in a way that genuinely serves our nonprofit mission by lowering costs, improving quality, and enhancing the member and physician experience.
We strive to create a diverse, equitable, and inclusive environment where all employees can be their authentic selves and fully contribute to meet the needs of the multifaceted communities we serve.
Our continued commitment to diversity, equity, and inclusion upholds our values and advances our goal of creating a healthcare system that is worthy of our family and friends while addressing health disparities, promoting social justice, and integrating health equity through our products, business practices, and presence as a corporate citizen.
We are proud to be a certified Fortune 100 Best Companies to Work, Military Friendly Employer, People Companies that Care, a Leading Disability Employer, and one of California's top companies in volunteering and giving.
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