Utilization Management Nurse, Senior (Medicare Concurrent Review)

Blue Shield of California•Rancho Cordova, CA

1d•$90,860 - $153,636•Hybrid

About The Position

The Utilization Management Concurrent Review Nurse reviews inpatient stays for members and applies guidelines for nationally recognized levels of care. Reporting to the Utilization Management Nurse Manager, this role performs first-level determinations for authorization requests using BSC evidence-based guidelines, policies, and nationally recognized criteria for the Medicare line of business. The nurse conducts reviews based on medical necessity and clinical judgment and requires detailed knowledge of benefit plans. The role performs prospective, concurrent, and retrospective utilization reviews; evaluates medical necessity, coding accuracy, medical policy compliance, and contract compliance; and supports appropriate discharge planning based on members’ needs and acuity. It prepares cases for Medical Director oversight and communicates determinations to providers and/or members in compliance with applicable requirements. The nurse also develops member-centered documentation, identifies potential quality-of-care issues and treatment delays, refers members to Case Management when acute inpatient needs affect discharge, and supports new employees. The position allows employees to work virtually full-time, with office attendance based on business need. The work environment includes home office/deskwork and physical offices as needed. The activity level is sedentary for most of the workday.

Requirements

Maintain an active, unrestricted California RN license.
Associate’s degree in nursing.
At least 5 years of prior relevant experience.
Strong communication and computer navigation skills.
Independent motivation and a strong work ethic.
Strong critical-thinking skills.

Nice To Haves

Bachelor of Science in Nursing preferred.
Strong teamwork and collaboration skills desired.

Responsibilities

Perform prospective, concurrent, and retrospective utilization reviews and first-level determination approvals for members using BSC and CMS evidence-based guidelines, policies, and nationally recognized clinical criteria for the BSC Medicare line of business.
Conduct clinical reviews for medical necessity, coding accuracy, medical policy compliance, and contract compliance.
Ensure discharge planning at all levels of care is appropriate for member needs and acuity; determine post-acute needs, including levels of care, durable medical equipment, and post-service needs, to support quality- and cost-appropriate discharge planning.
Prepare and present cases to the Medical Director for oversight and medical necessity determinations, then 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 and service or treatment delays, and intervene as clinically appropriate.
Refer members to Case Management when acute inpatient needs affect discharge.
Attend staff meetings, clinical rounds, and weekly huddles.
Maintain quality and productivity metrics for all casework.
Buddy with or support new employees.
Maintain a HIPAA-compliant workspace for the telework environment.