Utilization Management Nurse, Senior (NICU)

Your Role

The Utilization Management team reviews inpatient stays for our members and correctly applies the guidelines for nationally recognized levels of care for our Shared Services departments including concurrent review, transplant, and NICU/HROB. The Utilization Management Nurse, Senior will report to the Manager, Utilization and Medical Review. In this role you will be performing first level determination approvals for members using BSC evidenced based guidelines, policies, and nationally recognized clinical criteria across lines of business or for a specific line of business such as Medicare and FEP. Successful RN candidate reviews prior auth requests for medical necessity, coding accuracy and medical policy compliance. Clinical judgment and detailed knowledge of benefit plans used to complete review decisions is required.

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 
• Conduct 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 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 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 
• Triage and prioritize cases to meet required turn-around times and expedites access to appropriate care for members with urgent needs
• Provide referrals to Case Management, Disease Management, Appeals and Grievance and Quality Departments, as necessary
• Other duties as assigned

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
• Requires practical knowledge of job area typically obtained through advanced education combined with experience in NICU/HROB