Utilization Management Registered Nurse, Senior - California Children Services

Company: Blue Shield of California
Location: Los Angeles
Posted on: February 23, 2021

Job Description:

Job DescriptionThe Health Care Quality and Affordability team is made up of about 1,000 doctors, nurses, pharmacists, strategists, industry experts and innovators with a single vision - to transform the delivery of health care. Every day, we work together to improve the quality of patient care for our members while lowering health Care costs to ensure all Californians have access to the care they deserve.How do we do it? Through partnership, innovation, and thought leadership.We continue to expand our network of providers to ensure state-wide access to care. We evaluate analytic and digital health tools that simplify care delivery while improving member health status, health care quality and affordability as well as member and provider experience. We provide high-touch services to members from experienced clinical teams. You'll also find us collaborating with our federal and state legislative officials to help shape policy to advance our Blue Shield missionPerform clinical review, assessment, evaluation of medical services for the organization using the established and approved Blue Shield Medical Policies which align with nationally recognized standards. Responsible for managing member needs for specific clinical programs. Responsible in assisting and working daily inventory, providing high-quality clinical reviews, performing efficient case management and care coordination, and ensuring compliance performance metrics are met.Responsibilities* Performs 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.* Reviews for medical necessity, coding accuracy, medical policy compliance and contract compliance. Ensures diagnosis matches ICD10 codes.* Solicits support from SME's, leads and managers as appropriate. Participates in huddles/ team meetings.* Conduct UM review activities for appropriate member treatment to meet Recommended Length of Stay based on medical necessity criteria.* Ensures discharge (DC) planning at levels of care appropriate for the members needs and acuity.* Ensures proper care coordination to meet the needs of the members.* Determines post-acute needs of member including levels of care, durable medical equipment, and post service needs to ensure quality and cost-appropriate DC planning.* Triages and prioritizes cases to meet required turn-around times.* Expedites access to appropriate care for members with urgent needs.* Prepares and presents cases to Medical Director (MD) for medical director oversight and necessity determination.* Communicate determinations to providers and/or members to in compliance with state, federal and accreditation requirements.* Develops and reviews member centered documentation and correspondence reflecting determinations in compliance with regulatory and accreditation standards.* Identifies potential quality of care issues, service or treatment delays and intervenes or as clinically appropriate.* Provides referrals to Case Management, Disease Management, Appeals and Grievance and Quality Departments as necessary.* Identifies potential over-payments: CISD reviews claims for Medical Necessity for Providers and--FCR reviews claim for Facility Compliance.* Identifies potential Third-Party Liability and Coordination of Benefit cases and notifies appropriate internal departments.* Assists in the development and implementation of a proactive approach to improve and standardize overall retro claims review for clinical perspectives.* Other duties as assigned.Knowledge, Education and--Experience* Current California RN license.* A minimum of 4 years' experience in Medi-Cal Clinical Review and Case Management.* A minimum of 2 years' experience with California Children Services program.* Demonstrated knowledge of CMS / DHCS protocols and requirements.* Demonstrated understanding of NCQA / CMS / DHCS regulatory audit requirements.* Bachelor's degree in a healthcare or business operations related field preferred but not required.* Has functional expertise within the area of responsibility.* Understands Blue Shield of California's mission and business plan.* Proficient with Microsoft Office tools.* Familiarity with Technical writing.* Development and implementation of Desk level Procedure.

Keywords: Blue Shield of California, Los Angeles , Utilization Management Registered Nurse, Senior - California Children Services, Executive , Los Angeles, California