Utilization Management Nurse, Consultant
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.
At Blue Shield of California we are parents, leader, students, visionaries, heroes, and providers.
Everyday we come together striving to fulfill our mission, to ensure all Californians have access to high-quality health care at a sustainably affordable price.
For more than 80 years, Blue Shield of California has been dedicated to transforming health care by making it more accessible, cost-effective, and customer-centric.
We are a not-for-profit, independent member of the Blue Cross Blue Shield Association with 6,800 employees, more than $20 billion in annual revenue and 4.
3 million members.
The company has contributed more than $500 million to Blue Shield of California Foundation since 2002 to have a positive impact on California communities.
Blue Shield of California is headquartered in Oakland, California with 18 additional locations including Sacramento, Los Angeles, and San Diego.
We're excited to share Blue Shield of California has received awards and recognition for LGBT diversity, quality improvement, most influential women in corporate America, Bay Area's top companies in volunteering & giving, and one of the world's most ethical companies.
Here at Blue Shield of California, we're striving to make a positive change across our industry and the communities we live in , Join us!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 Pay Range:
The pay range for this role is:
$ 109120.
00 to $ 163680.
00 for California.
Note:
Please note that this range represents the pay range for this and many other positions at Blue Shield that fall into this pay grade.
Blue Shield salaries are based on a variety of factors, including the candidate's experience, location (California, Bay area, or outside California), and current employee salaries for similar roles.
Recommended Skills Analytical Auditing Case Management Communication Ethics Hospice Estimated Salary: $20 to $28 per hour based on qualifications.
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.
At Blue Shield of California we are parents, leader, students, visionaries, heroes, and providers.
Everyday we come together striving to fulfill our mission, to ensure all Californians have access to high-quality health care at a sustainably affordable price.
For more than 80 years, Blue Shield of California has been dedicated to transforming health care by making it more accessible, cost-effective, and customer-centric.
We are a not-for-profit, independent member of the Blue Cross Blue Shield Association with 6,800 employees, more than $20 billion in annual revenue and 4.
3 million members.
The company has contributed more than $500 million to Blue Shield of California Foundation since 2002 to have a positive impact on California communities.
Blue Shield of California is headquartered in Oakland, California with 18 additional locations including Sacramento, Los Angeles, and San Diego.
We're excited to share Blue Shield of California has received awards and recognition for LGBT diversity, quality improvement, most influential women in corporate America, Bay Area's top companies in volunteering & giving, and one of the world's most ethical companies.
Here at Blue Shield of California, we're striving to make a positive change across our industry and the communities we live in , Join us!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 Pay Range:
The pay range for this role is:
$ 109120.
00 to $ 163680.
00 for California.
Note:
Please note that this range represents the pay range for this and many other positions at Blue Shield that fall into this pay grade.
Blue Shield salaries are based on a variety of factors, including the candidate's experience, location (California, Bay area, or outside California), and current employee salaries for similar roles.
Recommended Skills Analytical Auditing Case Management Communication Ethics Hospice Estimated Salary: $20 to $28 per hour based on qualifications.
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