Utilization Management Nurse, Senior (Medicare Concurrent Review)

Blue Shield of California•Rancho Cordova, CA

2d•Remote

About The Position

The Utilization Management Nurse, Senior works on the Utilization Management Concurrent Review team, reviewing members’ inpatient stays and applying guidelines for nationally recognized levels of care. Reporting to the Utilization Management Nurse Manager, the nurse performs first-level determinations for authorization requests using BSC evidence-based guidelines, policies, and nationally recognized criteria for the Medicare line of business. The role includes evaluating requests for medical necessity using clinical judgment and applying detailed knowledge of benefit plans. The position conducts prospective, concurrent, and retrospective utilization reviews; evaluates discharge and post-acute care needs; prepares cases for Medical Director review; communicates determinations; and creates compliant member-centered documentation. The nurse also identifies potential quality-of-care issues and service or treatment delays, supports referrals to Case Management, maintains casework quality and productivity, and supports new employees. The role is virtual full-time, with in-office attendance required based on business need.

Requirements

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

Nice To Haves

Bachelor of Science in Nursing preferred.

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 BSC Medicare.
Conduct clinical reviews for medical necessity, coding accuracy, medical policy compliance, and contract compliance.
Ensure discharge planning at all levels of care is appropriate to members’ needs and acuity, and 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 determination, 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 in the telework environment.