Utilization Management Nurse, Senior (Prior Authorization - CalPERS)

Your RoleThe 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 WorkIn 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 criteriaConducts clinical review of cases for medical necessity, coding accuracy, medical policy compliance and contract complianceProvides SME and support to team members Conduct UM review activities for appropriate member treatment to meet appropriateness of care based on medical necessity criteriaTriages and prioritizes cases to meet required turn-around timesExpedites access to appropriate care for members with urgent needsPrepare 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 requirementsDevelop and review member centered documentation and correspondence reflecting determinations in compliance with regulatory and accreditation standardsIdentify potential quality of care issues, service or treatment delays, and apply interventions when clinically appropriateProvides referrals to Case Management, Disease Management, Appeals and Grievance, and Quality Departments as necessaryAttend staff meetings, clinical rounds and weekly huddlesMaintain quality and productivity metrics for all caseworkMaintaining HIPAA compliant workspace for telework environment

Your Knowledge and ExperienceBachelors of Science in Nursing or advanced degree preferredRequires a current California RN LicenseRequires at least 5 years of prior relevant experienceHealth plan experience preferredPrior Authorization experience preferredRequires strong written and oral communication skillsStrong analytical and problem-solving skillsStrong teamwork and collaboration skillsRequires 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.#LI-RU1