Utilization Management Nurse, Senior

Blue Shield of California•Rancho Cordova, CA

1d•Hybrid

About The Position

Your Role The Utilization Management team manages accurate and timely prior authorization and inpatient stays reviews for our members and correctly applies the guidelines for nationally recognized levels of care for our Shared Services department including concurrent review, transplant and NICU/HROB. The Utilization Management Nurse, Consultant will report to the Manager, Utilization and Medical Review. In this role you will be supporting the department by supporting the clinicians who perform first level determination approvals for members using BSC evidenced based guidelines, policies, and nationally recognized clinical criteria across lines of business or for a specific line of business such as Commercial, Medi-Cal or Medicare. Successful RN candidate reviews authorization requests for medical necessity, coding accuracy and medical policy compliance. Clinical judgment and detailed knowledge of benefit plans used to complete review decisions is required. The Utilization Management Nurse, Consultant will support the department operations by assisting with case review, auditing, responding to inquiries, training, and system testing. Our leadership model is about developing great leaders at all levels and creating opportunities for our people to grow – personally, professionally, and financially. We are looking for leaders that are energized by creative and critical thinking, building and sustaining high-performing teams, getting results the right way, and fostering continuous learning. Responsibilities Your Work In this role, you will:

Requirements

Bachelor of Science in Nursing or advanced degree preferred
Requires a current California RN License
Requires at least 5 years of prior relevant experience
Requires strong communication and computer navigation skills
Requires independent motivation and strong work ethic
Requires strong critical thinking skills

Nice To Haves

Desires strong teamwork and collaboration skills

Responsibilities

Perform prospective, concurrent and retrospective utilization reviews and first level determination approvals for members using BSC evidenced based guidelines, policies and nationally recognized clinal criteria across lines of business or for a specific line of business such as Commercial, Medi-Cal and Medicare
Review 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
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 intervenes or as clinically appropriate
Support team through consistent and successful caseload management and workload to achieve team goals, regulatory timelines, and accreditation standards
Support team through scheduled system and letter testing to achieve team goals, regulatory requirements, and accreditation standards
Support team through conducting department new hire and supplemental training
Support team through performing monthly internal case auditing to achieve team goals, regulatory timelines, and accreditation standards
Triages and prioritizes cases to meet required turn-around times and expedites access to appropriate care for members with urgent needs
Other duties as assigned
Maintain a HIPAA compliant workspace for telework environment