What are the responsibilities and job description for the Medical Records Nurse position at Blue Shield of California?
Job Title: Utilization Management Nurse
About the Role
The Utilization Management team at Blue Shield of California reviews inpatient stays for our members and applies nationally recognized guidelines for 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 inpatient facilities to determine medical necessity.
Key Responsibilities
- Perform prospective, concurrent, and retrospective utilization reviews using BSC evidenced-based guidelines, policies, and nationally recognized clinical criteria.
- Conduct clinical reviews of claims for medical necessity, coding accuracy, medical policy compliance, and contract compliance.
- Ensure discharge planning is aligned with members' needs and acuity, determining post-acute needs including levels of care, durable medical equipment, and post-service needs.
- Prepare and present cases to Medical Directors for oversight and necessity determination, communicating determinations to providers and/or members as required.
- Develop and review member-centered documentation and correspondence reflecting determinations in compliance with regulatory and accreditation standards.
Requirements
- Bachelor's of Science in Nursing or advanced degree preferred.
- Current California RN License required.
- Strong communication and computer navigation skills.
