Senior Utilization Management Nurse

2 weeks ago

Oakland, California, United States Blue Shield of CA Full time

Job Summary

The Senior Utilization Management Nurse will be responsible for reviewing inpatient stays for our members under nationally recognized levels of care guidelines. This role requires a strong clinical background and excellent analytical skills to determine medical necessity of admissions, appropriate length of stay, and level of care.

Key Responsibilities

  • 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, 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.
  • 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.

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: $ to $ 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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