Utilization Management Nurse, Consultant

Blue Shield of California•El Dorado, AR

About The Position

Your Role The Federal Employee Program (FEP) team is committed to providing quality healthcare coverage to federal employees, retirees, and their families. The FEP Utilization Management Nurse Consultant (Lead) will report to the FEP Utilization Management Medical Review Manager. In this role you will be part of a dynamic team responsible for prior authorization, concurrent, and post service medical reviews. You will ensure members receive services at the right level of care at the right time, appropriate, medically necessary, and within their benefit. Ultimately, it contributes to decreasing the cost of healthcare. Our leadership model is about developing great leaders at all levels and creating opportunities for our people to grow – personally, professionally, and financially. We are looking for leaders that are energized by creative and critical thinking, building and sustaining high-performing teams, getting results the right way, and fostering continuous learning. Responsibilities Your Work In this role, you will: Perform prospective, concurrent and retrospective utilization reviews and first level determination approvals for members using BSC evidenced based guidelines, policies and nationally recognized clinal criteria across lines of business or for a specific line of business such as Medicare and FEP Review for medical necessity, coding accuracy, medical policy compliance and contract compliance Ensure discharge (DC) planning at levels of care appropriate for the members needs and acuity and determine post-acute needs of member including levels of care, durable medical equipment, and post service needs to ensure quality and cost-appropriate DC planning Develop and review member centered documentation and correspondence reflecting determinations in compliance with regulatory and accreditation standards and identify potential quality of care issues, service or treatment delays and intervenes or as clinically appropriate Support team through consistent and successful caseload management and workload to achieve team goals, regulatory timelines, and accreditation standards Provide referrals to Case Management, Disease Management, Appeals and Grievance and Quality Departments as necessary. Identifies potential Third-Party Liability and Coordination of Benefit cases and notifies appropriate internal departments. Actively participate in staff meetings and huddles. Provide input into desk level procedures, and precept new employees. Perform monthly clinical staff audits for the concurrent review clinical teams and generally, responsible for providing guidance, coaching, and training to other employees within job area. Act as a tester for the UM documentation system and sign-off the system for production Generally, responsible for providing guidance, coaching, and training to other employees within job area. Provide clinical coverage for preservice, concurrent review, and post service as needed for vacations, sabbaticals, leave of absences, and periods of high caseloads. Collaborate with leadership on special projects as assigned.

Requirements

Requires a bachelor's degree or equivalent experience
Requires a current California RN License
Requires at least 7 years of prior relevant experience
Strong computer skills related to MS Suite
Demonstrated ability to independently assess, evaluate, and interpret clinical information and care planning
Strong clinical documentation skills, independent problem identification and resolution skills
Excellent analytical and problem-solving skills
Must be able to sit for extended periods of time and read clinical information on one computer screen and apply that information based on criteria or policy on a second screen to document the decision
Work is performed with limited oversight

Nice To Haves

4 years clinical experience preferred
Previous experience in utilization management preferred
Working knowledge of regulatory and accreditation standards preferred (URAC, NCQA, DMHC, Case Management Society of America CMSA)

Responsibilities

Perform prospective, concurrent and retrospective utilization reviews and first level determination approvals for members using BSC evidenced based guidelines, policies and nationally recognized clinal criteria across lines of business or for a specific line of business such as Medicare and FEP
Review for medical necessity, coding accuracy, medical policy compliance and contract compliance
Ensure discharge (DC) planning at levels of care appropriate for the members needs and acuity and determine post-acute needs of member including levels of care, durable medical equipment, and post service needs to ensure quality and cost-appropriate DC planning
Develop and review member centered documentation and correspondence reflecting determinations in compliance with regulatory and accreditation standards and identify potential quality of care issues, service or treatment delays and intervenes or as clinically appropriate
Support team through consistent and successful caseload management and workload to achieve team goals, regulatory timelines, and accreditation standards
Provide referrals to Case Management, Disease Management, Appeals and Grievance and Quality Departments as necessary.
Identifies potential Third-Party Liability and Coordination of Benefit cases and notifies appropriate internal departments.
Actively participate in staff meetings and huddles.
Provide input into desk level procedures, and precept new employees.
Perform monthly clinical staff audits for the concurrent review clinical teams and generally, responsible for providing guidance, coaching, and training to other employees within job area.
Act as a tester for the UM documentation system and sign-off the system for production
Generally, responsible for providing guidance, coaching, and training to other employees within job area.
Provide clinical coverage for preservice, concurrent review, and post service as needed for vacations, sabbaticals, leave of absences, and periods of high caseloads.
Collaborate with leadership on special projects as assigned.