Nursing, Pharmacy Health Services - Nurse RN

Position: Nursing, Pharmacy, & Health Services - Nurse RN 3
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 reviews the inpatient stays for our members and correctly applies the guidelines for nationally recognized levels of care. The Utilization Management Nurse will report to the Utilization Management Nurse Manager. In this role you will be assigned a list of inpatient facilities and then review clinical information provided by the facilities to determine medical necessity when our members admit.

You will also be involved with discharge planning and transfers as needed for higher levels of care or out of network admissions.

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 and FEP

• Conducts clinical review of claims 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

• Prepare and present cases to Medical Director (MD) for medical director oversight and necessity determination and communicate determinations to providers and/or members to in compliance with state, federal and accreditation requirements

• 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

• Refer to Case Management when there are acute inpatient needs affecting discharge

• Attend staff meetings, clinical rounds and weekly huddles

• Maintain quality and productivity metrics for all casework

• Buddy or support new employees

• Maintaining HIPAA compliant workspace for telework environment

Your Knowledge and Experience

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

Education/

Experience:

• Associate's degree in nursing required. Bachelor's degree preferred.

• Nursing license required.

• 5-7 years experience required.