Utilization Management Nurse, Consultant

Job Description

Your Role

The Federal Employee Program (FEP) team is committed to providing quality healthcare coverage to federal employees, retirees, and their family. The FEP Utilization Management Nurse Consultant (Lead) will report to the FEP Utilization Management Medical Review Manager. In this role you will be part of a dynamic team responsible for prior authorization, concurrent, and post service medical reviews. You will ensure members receive services at the right level of care at the right time, appropriate, medically necessary, and within their benefit. Ultimately contributing to decreasing the cost of healthcare.

Responsibilities

Your Work

In this role, you will:

• Perform prospective, concurrent, and retrospective utilization reviews and first level determination approvals for members using FEP and BSC evidenced based guidelines, policies and nationally recognized clinal criteria.
• Conduct clinical review of prior authorization, concurrent, and post service requests for medical necessity, coding accuracy, medical policy compliance and contract compliance.
• Ensure discharge(DC) planning at levels of care appropriate for the members needs.
• 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.
• Provide referrals to Case Management, Disease Management, Appeals and Grievance and Quality Departments as necessary. Identifies potential Third-Party Liability and Coordination of Benefit cases and notifies appropriate internal departments.
• Actively participate in staff meetings and huddles.
• Provide input into desk level procedures, and precept new employees.
• Perform monthly clinical staff audits for the concurrent review clinical teams and generally, responsible for providing guidance, coaching, and training to other employees within job area.
• Act as a tester for the UM documentation system and sign-off the system for production
• Generally, responsible for providing guidance, coaching, and training to other employees within job area.
• Provide clinical coverage for preservice, concurrent review, and post service as needed for vacations, sabbaticals, leave of absences, and periods of high caseloads.
• Collaborate with leadership on special projects as assigned.

Qualifications

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
• Previous experience in utilization management preferred
• Strong computer skills related to Windows-based programs and applications
• Varied acute care clinical background
• Demonstrated ability to independently assess, evaluate, and interpret clinical information and care planning
• Strong clinical documentation skills, independent problem identification and resolution skills
• Excellent analytical and problem-solving skills
• Working knowledge of regulatory and accreditation standards preferred (URAC, NCQA, DMHC, Case Management Society of America CMSA)
• Must be able to sit for extended periods of time and read clinical information on one computer screen and apply that information based on criteria or policy on a second computer screen to document the decision
• Work is performed with limited oversight

About the Team

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 genuinely 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 continued commitment to diversity, equity, and inclusion upholds our values and advances our goal of creating a healthcare system that is worthy of our family and friends while addressing health disparities, promoting social justice, and integrating health equity through our products, business practices, and presence as a corporate citizen.

Blue Shield has received awards and recognition for being a certified Fortune 100 Best Companies to Work, Military Friendly Employer, People Companies that Care, a Leading Disability Employer, and one of California's top companies in volunteering and giving. Here at Blue Shield, we strive to make a positive change across our industry and communities - join us!

Our Values:

• Honest. We hold ourselves to the highest ethical and integrity standards. We build trust by doing what we say we're going to do and by acknowledging and correcting where we fall short.
• Human. We strive to be our authentic selves, listening and communicating effectively, and showing empathy towards others by walking in their shoes.
• Courageous. We stand up for what we believe in and are committed to the hard work necessary to achieve our ambitious goals.

Our Workplace Model:

At Blue Shield of California, we believe in fostering a workplace environment that balances purposeful in-person collaboration with flexibility. As we continue to evolve our workplace model, our focus remains on creating spaces where our people can connect with purpose - whether working in the office or through a hybrid approach - by providing clear expectations while respecting the diverse needs of our workforce.

Two Ways of Working:

• Hybrid (Default): Work from a business unit-approved office at least two (2) times per month (for roles below Director-level) or once per week (for Director-level roles and above).Exceptions:
  
  • Member-facing and approved out-of-state roles remain remote.
  • Employees living more than 50 miles from their assigned offices are expected to work with their managers on a plan for periodic office visits.
  • For employees with medical conditions that may impact their ability to work in-office, we are committed to engaging in an interactive process and providing reasonable accommodations to ensure their work environment is conducive to their success and well-being.
• On-Site: Work from a business unit-approved office an average of four (4) or more days a week.

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.

Please click here for further physical requirement detail.

Equal Employment Opportunity:

External hires must pass a background check/drug screen. Qualified applicants with arrest records and/or conviction records will be considered for employment in a manner consistent with Federal, State and local laws, including but not limited to the San Francisco Fair Chance Ordinance. All qualified applicants will receive consideration for employment without regards to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran status or disability status and any other classification protected by Federal, State and local laws.