Your Role

The Utilization Management team reviews the inpatient stays for our members under 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 review clinical information provided by the facilities to determine medical necessity of admissions, appropriate length of stay and level of care. You will also be responsible for discharge planning and transfers as needed for next appropriate levels of care, or out of network admissions.

Your Work

In this role, you will:

• Perform prospective utilization reviews and first level determination approvals for members using BSC evidenced based guidelines, policies and nationally recognized clinal criteria
• Conducts clinical review of cases for medical necessity, coding accuracy, medical policy compliance and contract compliance
• Provides SME and support to team members Conduct UM review activities for appropriate member treatment to meet appropriateness of care based on medical necessity criteria
• Triages and prioritizes cases to meet required turn-around times
• Expedites 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 to 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
• Provides 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
• Maintaining HIPAA compliant workspace for telework environment

Your Knowledge and Experience

• Bachelors of Science in Nursing or advanced degree preferred
• Requires a current California RN License
• Requires at least 5 years of prior relevant experience
• Health plan experience preferred
• Prior Authorization experience preferred
• Requires strong written and oral communication skills
• Strong analytical and problem-solving skills
• Strong teamwork and collaboration skills
• Requires independent motivation and strong work ethic

Pay Range:

The pay range for this role is: $ 87230.00 to $ 130900.00 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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