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Clinical Utilization Review Specialist
2 months ago
We are seeking a highly skilled Senior Utilization Management Nurse 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 minimizing unnecessary costs.
Key Responsibilities- Perform prospective, concurrent, and retrospective utilization reviews to determine medical necessity and ensure compliance with national guidelines and policies.
- Conduct clinical reviews of claims to ensure accuracy, medical policy compliance, and contract compliance.
- Develop and implement discharge planning strategies to ensure members receive appropriate levels of care and post-acute services.
- Prepare and present cases to Medical Directors for oversight and determination, and communicate findings to providers and members.
- Maintain accurate and detailed documentation of reviews and determinations, and identify potential quality of care issues and intervene as necessary.
- Current California RN License
- At least 5 years of prior relevant experience
- Bachelor of Science in Nursing or advanced degree preferred
- Strong communication, computer navigation, and teamwork skills
We offer a competitive salary range of $87,230.00 to $130,900.00 for California, and a comprehensive benefits package. If you are a motivated and detail-oriented professional with a passion for healthcare, we encourage you to apply for this exciting opportunity.
