Clinical Utilization Review Specialist

Job Description

The Utilization Management Team at Blue Shield of California reviews inpatient stays for our members and applies nationally recognized guidelines for care. As a Medical Records Nurse, you will be responsible for reviewing clinical information provided by facilities to determine medical necessity when our members admit. You will also be involved in discharge planning and transfers as needed for higher levels of care or out-of-network admissions.

Key responsibilities include:

1. Performing prospective, concurrent, and retrospective utilization reviews and approvals for members using evidence-based guidelines, policies, and nationally recognized clinical criteria.
2. Conducting clinical reviews of claims for medical necessity, coding accuracy, medical policy compliance, and contract compliance.
3. Ensuring discharge planning at levels of care appropriate for member needs and acuity, and determining post-acute needs including levels of care, durable medical equipment, and post-service needs.
4. Preparing and presenting cases to the Medical Director for oversight and determination, and communicating determinations to providers and/or members in compliance with state, federal, and accreditation requirements.
5. Developing and reviewing member-centered documentation and correspondence reflecting determinations in compliance with regulatory and accreditation standards, and identifying potential quality of care issues, service delays, and intervening as clinically appropriate.