What are the responsibilities and job description for the Nurse Clinical Reviewer position at Blue Shield of California?
Role Overview: Our company is seeking a skilled Nurse Clinical Reviewer to join our Care Coordination team. As a Nurse Clinical Reviewer, you will be responsible for reviewing clinical information provided by healthcare facilities to determine medical necessity for our members.
">">This role requires a strong background in nursing and experience with clinical review processes. You will work closely with the Utilization Management Nurse Manager to ensure that all determinations are made in compliance with regulatory requirements. Additionally, you will 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. This is an excellent opportunity for a dedicated nurse to make a meaningful impact on the lives of our members while working in a dynamic and collaborative environment.">">- Responsibilities:
- Conduct clinical reviews of claims for medical necessity, coding accuracy, medical policy compliance, and contract compliance
- Determine medical necessity for inpatient stays and develop discharge plans appropriate for the member's needs and acuity
- Prepare and present cases to Medical Director for oversight and necessity determination, and communicate 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
- Identify potential quality of care issues, service delays, or treatment issues and intervene as clinically appropriate
- Refer to Case Management when there are acute inpatient needs affecting discharge
- Attend staff meetings, clinical rounds, and weekly huddles
- Maintain quality and productivity metrics for all casework
- Maintain HIPAA-compliant workspace for telework environment
Requirements: To be successful in this role, you must possess a current California RN license, strong communication and computer navigation skills, and a Bachelor's degree in Nursing or advanced degree. If you are a motivated and detail-oriented nurse who is passionate about making a difference in the lives of others, we encourage you to apply.
