What are the responsibilities and job description for the Utilization Management Nurse position at Blue Shield of California?
About the Role: Blue Shield of California is seeking a talented Utilization Management Nurse to join our Care Coordination team. As a Utilization Management Nurse, you will play a critical role in ensuring that our members receive necessary care while minimizing unnecessary costs.
">">In this position, you will be responsible for conducting clinical reviews of claims to determine medical necessity, coding accuracy, medical policy compliance, and contract compliance. You will also 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 exciting 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:
- Review clinical information provided by healthcare facilities to determine medical necessity for our members
- 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
What We Offer: Blue Shield of California offers a competitive salary and benefits package, including health insurance, retirement plan, and paid time off. We are committed to supporting the growth and development of our employees through ongoing education and training opportunities.
