Utilization Management Nurse, Senior

Your Role

The CalPERS concurrent review  team oversees members admissions at inpatient settings along the continuum of care to ensure services are provided at the most appropriate level of care. The CalPERS Nurse Senior will report to the CalPERS Sr. Manager. In this role you will be part of a dynamic team that processes concurrent review cases based on regulatory and medical necessity guideline criteria.

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 for CalPERS members.
• 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 
• Actively participate in member rounds

Your Knowledge and Experience

• Bachelors of Science in Nursing or Advanced Degree preferred
• Requires a current California RN License 
• Requires at least 5 years of prior relevant experience
• CalPERS membership experience highly preferred 
• The ability to clearly convey information, actively listen, and adapt communication style to different audience is desired 
• Proficiency in AA, MS Suite, MCG, Facets, and SharePoint desired