RN / Case Management / California / Permanent / Utilization Management Nurse, Senior Job
Company: Blue Shield of California
Location: Rancho Cordova
Posted on: May 25, 2023
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Job Description:
Utilization and Medical Review: Ensures accurate and timely
prior authorization of designated healthcare services. Utilization
Management Nurse:Performs prospective, first level determination
approvals for members using BSC evidenced based guidelines,
policies and nationally recognized clinical criteria across lines
of business or for a specific line of business such as FEP. Reviews
for medical necessity, coding accuracy, medical policy compliance
and contract compliance. Clinical judgment and detailed knowledge
of benefit plans used to complete review decisions. Essential
Responsibilities: Reviews for medical necessity, coding accuracy,
medical policy compliance and contract compliance. Ensures
diagnosis matches ICD10 codes. Solicits support from SME's, leads
and managers as appropriate. Participates in huddles/ team
meetings. Triages and prioritizes cases to meet required
turn-around times. Expedites access to appropriate care for members
with urgent needs. Prepares and presents cases to Medical Director
(MD) for medical director oversight and necessity determination.
Communicate determinations to providers and/or members to in
compliance with state, federal and accreditation requirements.
Develops and reviews member centered documentation and
correspondence reflecting determinations in compliance with
regulatory and accreditation standards. Identifies potential
quality of care issues, service or treatment delays and intervenes
or as clinically appropriate. Provides referrals to Case
Management, Disease Management, Appeals and Grievance and Quality
Departments as necessary. Identifies potential over-payments: -
CISD reviews claims for Medical Necessity for Providers - FCR
reviews claim for Facility Compliance Identifies potential
Third-Party Liability and Coordination of Benefit cases and
notifies appropriate internal departments. Assists in the
development and implementation of a proactive approach to improve
and standardize overall retro claims review for clinical
perspectives. Other duties as assigned
Keywords: Blue Shield of California, Rancho Cordova , RN / Case Management / California / Permanent / Utilization Management Nurse, Senior Job, Executive , Rancho Cordova, California
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