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Utilization Management Nurse, Consultant

Company: Blue Shield of California
Location: Rancho Cordova
Posted on: September 18, 2022

Job Description:

Blue Shield of California's mission is to ensure all Californians have access to high-quality health care at a sustainably affordable price. We are transforming health care in a way that truly serves our nonprofit mission by lowering costs, improving quality, and enhancing the member and physician experience. To fulfill our mission, we must ensure a diverse, equitable, and inclusive environment where all employees can be their authentic selves and fully contribute to meet the needs of the multifaceted communities we serve. Our comprehensive approach to DE&I combines a focus on our people processes and systems with a deep commitment to promoting social justice and health equity through our products, business practices, and presence as a corporate citizen. Blue Shield has received awards and recognition for being a certified Great Place to Work, best place to work for LGBTQ equality, leading disability employer, one of the best companies for women to advance, Bay Area's top companies in volunteering & giving, and one of the world's most ethical companies. Here at Blue Shield of California, we are striving to make a positive change across our industry and the communities we live in - join us Your Role The Utilization Management team facilitates the review of requests for medical necessity to assure that care is provided to our members timely, at the correct level of care with quality and cost effectiveness standards. The Utilization Management Nurse Consultant will report to the Utilization Management Manager. In this role you will be an individual with advanced level knowledge. Considered the subject matter expert (SME) and could engage in project or program management activities. 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, MediCal and FEP Review for medical necessity, coding accuracy, medical policy compliance, benefit eligibility and contract compliance Identifies potential Third Party Liability and Coordination of Benefit Cases and notifies appropriate parties/departments. 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 . Provides referrals to Case management, Palliative Care, Disease Management, Appeals & Grievances and quality Departments as needed. 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 Triages and prioritizes cases and other assigned duties to meet required turn around times. Prepares and presents cases to Medical Director (MD) for medical director oversight and necessity determinations. Communications determinations to providers and/or members in compliance with regulatory and accreditation requirements. Performs staff compliance audits and provides education to promote quality improvement Facilitate/scribe team meetings to engage staff, support processes and collaboration of team members. Provides SME and support to overall team. Your Knowledge and Experience Requires a bachelor's degree or equivalent experience Requires a current California RN License Requires at least 7 years of prior relevant experience Demonstrates analytical and problem solving skills Demonstrates effective written and oral communication skills Desired broad knowledge of project management Our Values Honest. We hold ourselves to the highest ethical and integrity standards. We build trust by doing what we say we're going to do and by acknowledging and correcting where we fall short. Human. We strive to be our authentic selves, listening and communicating effectively, and showing empathy towards others by walking in their shoes. Courageous. We stand up for what we believe in and are committed to the hard work necessary to achieve our ambitious goals. PDN-96ebde2c-31ce-4395-81d3-ae5777a71a2a

Keywords: Blue Shield of California, Rancho Cordova , Utilization Management Nurse, Consultant, Professions , Rancho Cordova, California

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