Your Role
The Utilization Management team reviews the inpatient stays for our members and correctly applies the guidelines for nationally recognized levels of care. The Utilization Management Nurse, Senior will report to the Utilization Management Nurse Manager. In this role you will be assigned a list of inpatient facilities and then review clinical information provided by the facilities to determine medical necessity when our members admit. This role will also be involved with discharge planning and transfers as needed for higher levels of care or out of network admissions.
Your Work
In this role, you will:
- Perform prospective, concurrent and retrospective utilization reviews and first level determination approvals for members using Blue Shield of California (BSC) evidenced based guidelines, policies, and nationally recognized clinical criteria across lines of business or for a specific line of business such as Medicare and FEP
- Conduct clinical review of claims for medical necessity, coding accuracy, medical policy compliance, and contract compliance
- Ensure discharge (DC) planning at levels of care appropriate for the members needs and acuity, and determine post-acute needs of member including levels of care, durable medical equipment, and post service needs to ensure quality and cost-appropriate DC planning
- Prepare and present cases to Medical Director (MD) for medical director oversight and necessity determination and communicate determinations to providers and/or members to be 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 and identify potential quality of care issues, service or treatment delays, and intervene as clinically appropriate
- Refer to Case Management when there are acute inpatient needs affecting discharge
- Attend staff meetings, clinical rounds, and weekly huddles
- Maintain quality and productivity metrics for all casework
- Maintain HIPAA compliant workspace for telework environment
- Perform other duties as assigned
Your Knowledge and Experience
- Requires a current California RN License
- Requires at least 5 years of prior relevant experience
- Bachelor of Science in Nursing or advanced degree preferred
- Strong communication and computer navigation skills is preferred
- Strong teamwork and collaboration skills is preferred
- Independent motivation and strong work ethic is preferred
- Strong critical thinking skills is preferred
Pay Range:
The pay range for this role is: $87,230.00 to $130,900.00 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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