Utilization Management Nurse, Senior (Prior Authorization - CalPERS)

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.

#LI-RU1

Utilization Management Nurse, Senior (Prior Authorization - CalPERS) at Blue Shield of California summary:The Senior Utilization Management Nurse conducts clinical reviews to assess the medical necessity of inpatient admissions and length of stay, ensuring compliance with regulations. This role involves collaborating with healthcare teams, preparing cases for Medical Director review, and addressing urgent care needs effectively. Applicants must possess a California RN License and have a minimum of five years of relevant experience in healthcare, preferably in utilization management and prior authorization.

Keywords:Utilization Management, Nurse, Prior Authorization, Medical Necessity, Healthcare, Case Management, Clinical Review, California RN License, Quality of Care, Telework