Utilization Management Nurse, Senior (Medicare Concurrent Review)

Your Role

The Utilization Management Concurrent Review team reviews the inpatient stays for our members and correctly applies guidelines for nationally recognized levels of care. The Utilization Management Concurrent Review Nurse will report to the Utilization Management Nurse Manager. In this role you will perform first level determination for authorization requests received for members using BSC evidence-based guidelines, policies, and nationally recognized criteria across specific lines of business such as Medicare, Medical, or Commercial plans. You will conduct reviews for authorization requests based on medical necessity and clinical judgment. Detailed knowledge of the benefit plans is necessary to complete review decisions.

Your Work

In this role, you will

• Perform prospective, concurrent and retrospective utilization reviews and first level determination approvals for members using BSC and CMS evidenced based guidelines, policies and nationally recognized clinal criteria for BSC Medicare line of business.
• Conduct clinical review for medical necessity, coding accuracy, medical policy compliance and contract compliance
• Ensure that discharge planning at all levels of care is appropriate for the member’s needs and acuity, and determine post-acute needs of members including levels of care, durable medical equipment, and post service needs to ensure quality and cost appropriate DC planning
• Prepare and present cases to the Medical Director for medical director oversight and necessity determination then communicate the determinations to providers and/or members 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 for new employees
• Maintaining HIPAA compliant workspace for telework environment

Your Knowledge and Experience

• Must maintain an active, unrestricted CA RN license
• Associate’s degree in nursing is required
• Bachelor of Science in Nursing is preferred
• 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.