Utilization Management Nurse, Senior

Blue Shield of California•El Dorado, AR

19h•Hybrid

About The Position

The Utilization Management Nurse, Senior supports the Utilization Management team in conducting accurate and timely prior authorization and inpatient stay reviews for members. The team applies guidelines for nationally recognized levels of care for the Shared Services department, including concurrent review, transplant, and NICU/HROB. The role supports clinicians performing first-level determination approvals using BSC evidence-based guidelines, policies, and nationally recognized clinical criteria across lines of business or within a specific line of business, such as Commercial, Medi-Cal, or Medicare. The nurse reviews authorization requests for medical necessity, coding accuracy, and medical policy compliance, using clinical judgment and detailed knowledge of benefit plans. The position also supports department operations through case review, auditing, responding to inquiries, training, and system testing. The role reports to the Manager, Utilization and Medical Review. Although employees may work virtually full-time, they are expected to come to the office based on business need.

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.
Strong critical-thinking skills.
Independent motivation and a strong work ethic.

Nice To Haves

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

Responsibilities

Perform prospective, concurrent, and retrospective utilization reviews and first-level determination approvals using BSC evidence-based guidelines, policies, and nationally recognized clinical criteria.
Review cases for medical necessity, coding accuracy, medical policy compliance, and contract compliance.
Ensure discharge planning is appropriate to members’ needs and acuity, and determine post-acute needs, including levels of care, durable medical equipment, and post-service needs.
Develop and review member-centered documentation and correspondence that reflect determinations and comply with regulatory and accreditation standards.
Identify potential quality-of-care issues and service or treatment delays, and intervene when clinically appropriate.
Manage caseloads and workloads to support team goals, regulatory timelines, and accreditation standards.
Conduct scheduled system and letter testing to support team goals, regulatory requirements, and accreditation standards.
Conduct department new-hire and supplemental training.
Perform monthly internal case auditing.
Triage and prioritize cases to meet required turnaround times and expedite access to appropriate care for members with urgent needs.
Maintain a HIPAA-compliant workspace in the telework environment.
Perform other duties as assigned.