What are the responsibilities and job description for the Clinical Review Nurse Specialist position at Blue Shield of California?
Job Overview
">The Utilization Management team at Blue Shield of California plays a crucial role in reviewing inpatient stays for our members and ensuring the correct application of nationally recognized levels of care. As a Utilization Management Nurse, you will report to the Utilization Management Nurse Manager and be responsible for reviewing clinical information provided by facilities to determine medical necessity when our members are admitted.
">Key Responsibilities
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- Perform prospective, concurrent, and retrospective utilization reviews and first-level determination approvals for members using BSC evidence-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 reviews of claims for medical necessity, coding accuracy, medical policy compliance, and contract compliance. ">
- Ensure discharge planning at levels of care appropriate for the member's needs and acuity, determining post-acute needs, including levels of care, durable medical equipment, and post-service needs to ensure quality and cost-appropriate discharge planning. ">
- Prepare and present cases to Medical Directors for oversight and necessity determination, communicating determinations to providers and/or members 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, identifying potential quality-of-care issues, service delays, and intervening as clinically appropriate. ">
Required Skills and Qualifications
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- Bachelor's of Science in Nursing or advanced degree preferred. ">
- Current California RN License required. ">
- Strong communication and computer navigation skills. ">
About Us
">Blue Shield of California is a leading health plan dedicated to providing high-quality healthcare services to its members. Our mission is to improve the health and well-being of Californians through innovative healthcare solutions.
