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Rancho Cordova, California, United States Blue Shield of California Full timeAbout the RoleWe are seeking a highly experienced and skilled Director, Medicare & Medi-Cal Utilization Management to join our team at Blue Shield of California. This critical role will play a key part in delivering and collaborating on all aspects of utilization management and care coordination for our Medicare and Medi-Cal membership.Key...
Utilization Management Nurse, Senior
2 months 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 the highest quality care while promoting cost-effective and efficient healthcare delivery.
Key Responsibilities- Concurrent Review and Approval: Perform concurrent utilization reviews and first-level determination approvals for members using BSC evidenced-based guidelines, policies, and nationally recognized clinical criteria.
- Clinical Review and Analysis: Conduct clinical reviews of cases for medical necessity, coding accuracy, medical policy compliance, and contract compliance.
- Subject Matter Expertise: Provide subject matter expertise and support to team members, conducting UM review activities for appropriate member treatment to meet Recommended Length of Stay based on medical necessity criteria.
- Discharge Planning: Ensure discharge planning at levels of care appropriate for members' needs and acuity, determining post-acute needs, including levels of care, durable medical equipment, and post-service needs, ensuring quality and cost-appropriate discharge planning.
- Case Triage and Prioritization: Triage and prioritize cases to meet required turn-around times.
- Access to Care: Expedite access to appropriate care for members with complex needs.
- Medical Director Oversight: Prepare and present cases to Medical Director for medical director oversight and necessity determination, communicating determinations to providers and/or members in compliance with state, federal, and accreditation requirements.
- Documentation and Correspondence: Develop and review member-centered documentation and correspondence reflecting determinations in compliance with regulatory and accreditation standards.
- Quality and Productivity Metrics: Maintain quality and productivity metrics for all casework.
- HIPAA Compliance: Maintain a HIPAA-compliant workspace for telework environment.
- Education: Bachelor's of Science in Nursing or advanced degree preferred.
- License: Current California RN License required.
- Experience: At least 5 years of prior relevant experience required.
- Healthcare Experience: Health plan experience preferred.
- Concurrent Review Experience: Concurrent review experience preferred.
- Communication and Analytical Skills: Strong written and oral communication skills required. Strong analytical and problem-solving skills required.
- Teamwork and Collaboration: Strong teamwork and collaboration skills required.
- Independent Motivation: Independent motivation and strong work ethic required.
