Job Description

Your Role

The Utilization Management team manages accurate and timely prior authorization and inpatient stays reviews for our members and correctly applies the guidelines for nationally recognized levels of care for our Shared Services department including concurrent review, transplant and NICU/HROB. The Utilization Management Nurse, Senior will report to the Manager, Utilization and Medical Review. In this role you will be supporting the department by supporting the clinicians who perform 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 Commercial, Medi-Cal or Medicare. Successful RN candidate reviews authorization requests for medical necessity, coding accuracy and medical policy compliance. Clinical judgment and detailed knowledge of benefit plans used to complete review decisions is required. The Utilization Management Nurse, Senior will support the department operations by assisting with case review, auditing, responding to inquiries, training, and system testing.

Responsibilities

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 Commercial, Medi-Cal and Medicare
• Review for medical necessity, coding accuracy, medical policy compliance and contract compliance
• 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
• 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
• Support team through scheduled system and letter testing to achieve team goals, regulatory requirements, and accreditation standards
• Support team through conducting department new hire and supplemental training
• Support team through performing monthly internal case auditing to achieve team goals, regulatory timelines, and accreditation standards
• Triages and prioritizes cases to meet required turn-around times and expedites access to appropriate care for members with urgent needs
• Other duties as assigned
• Maintain a HIPAA compliant workspace for telework environment

Qualifications

Your Knowledge and Experience

• Bachelor of Science in Nursing or advanced degree preferred
• Requires a current California RN License
• Requires at least 5 years of prior relevant experience
• Requires strong communication and computer navigation skills
• Desires strong teamwork and collaboration skills
• Requires independent motivation and strong work ethic
• Requires strong critical thinking skills

Hybrid Virtual Work

This role allows employees to work virtually full-time, however employees will be expected to come to the office based on business need.

Physical Requirements:

Office Environment - roles involving part to full time schedule in Office Environment. Based in our physical offices and work from home office/deskwork - Activity level: Sedentary, frequency most of work day.

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