Utilization Management Nurse, Senior (Prior Authorization - CalPERS) Job at Blue Shield of California, Rancho Cordova, CA

bC94d0xrODkwVmUyQjNobXNUTFEvRkowR1E9PQ==
  • Blue Shield of California
  • Rancho Cordova, CA

Job Description

Your Role

The Utilization Management team reviews the inpatient stays for our members under the guidelines for nationally recognized levels of care. The Utilization Management Nurse, Senior will report to the Utilization Management Nurse Manager. In this role you will be assigned a list of inpatient facilities and review clinical information provided by the facilities to determine medical necessity of admissions, appropriate length of stay and level of care. You will also be responsible for discharge planning and transfers as needed for next appropriate levels of care, or out of network admissions. 

 

Your Work

In this role, you will:

  • Perform prospective utilization reviews and first level determination approvals for members using BSC evidenced based guidelines, policies and nationally recognized clinal criteria
  • Conducts clinical review of cases for medical necessity, coding accuracy, medical policy compliance and contract compliance
  • Provides SME and support to team members Conduct UM review activities for appropriate member treatment to meet appropriateness of care based on medical necessity criteria
  • Triages and prioritizes cases to meet required turn-around times
  • Expedites access to appropriate care for members with urgent needs
  • Prepare and present cases to Medical Director (MD) for medical director oversight and necessity determination and communicate determinations to providers and/or members to 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 or treatment delays, and apply interventions when clinically appropriate
  • Provides referrals to Case Management, Disease Management, Appeals and Grievance, and Quality Departments as necessary
  • Attend staff meetings, clinical rounds and weekly huddles
  • Maintain quality and productivity metrics for all casework
  • Maintaining HIPAA compliant workspace for telework environment

Your Knowledge and Experience

  • Bachelors of Science in Nursing or advanced degree preferred
  • Requires a current California RN License 
  • Requires at least 5 years of prior relevant experience
  • Health plan experience preferred
  • Prior Authorization experience preferred
  • Requires strong written and oral communication skills
  • Strong analytical and problem-solving skills
  • Strong teamwork and collaboration skills
  • Requires independent motivation and strong work ethic

 

Pay Range: 

The pay range for this role is: $ 87230.00 to $ 130900.00 for California.

Note:

Please note that this range represents the pay range for this and many other positions at Blue Shield that fall into this pay grade. Blue Shield salaries are based on a variety of factors, including the candidate's experience, location (California, Bay area, or outside California), and current employee salaries for similar roles.

#LI-RU1

Job Tags

Contract work, Immediate start, Remote job,

Similar Jobs

Allegra Marketing Print Mail | 22nd & Park | Tucson

Print Production Manager Job at Allegra Marketing Print Mail | 22nd & Park | Tucson

 ...Park & 22 nd Street provides digital and print marketing communications services - from...  ...and creative development through production and delivery - for local and regional businesses...  ..., and energetic Print Production Manager to join our growing team and act as the... 

The Madison Collective - NYC

Bar Manager Job at The Madison Collective - NYC

 ...Description A celebrated James Beard darling is seeking a dynamic Beverage Manager to be responsible for overseeing the day to day operations of restaurant service. This role requires exceptional organizational and collaborative skills, attention to detail, and the... 

The Florida Panthers

Event Security Guard - D License Required Job at The Florida Panthers

 ...of what we are building in South Florida. Job Title: Event Security Guard - D License Required Department: Event Security Reports...  ...week (hours per week may vary due to event schedule), mostly nights, weekends, and possibly holidays. This position can be for multilple... 

Catholic Health Initiatives

VP Medical Operations, CMO Job at Catholic Health Initiatives

**Overview** CommonSpirit Health was formed by the alignment of Catholic Health Initiatives (CHI) and Dignity Health. With more than 700 care sites across the U.S. from clinics and hospitals to home-based care and virtual care services CommonSpirit is accessible to nearly...

ProLogistix

Conveyor Maintenance Mechanic Job at ProLogistix

 ...: Performs maintenance duties required in order to maintain conveyor system and equipment in a manufacturing environment. Position...  ...Qualifications: ~ Associates degree in Electrical or Mechanical field or 2-3+ years related experience. ~ Follow all safety...