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 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.

Your Work

In this role, you will:

• Provide clinical coverage for preservice, concurrent review, and post service as needed for vacations, sabbaticals, leave of absences, and periods of high caseloads.
• Act as a tester for the UM documentation system and sign-off the system for production
• 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.
• 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.
• 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.
• Conduct clinical review of prior authorization, concurrent, and post service requests for medical necessity, coding accuracy, medical policy compliance and contract compliance.
• Generally, responsible for providing guidance, coaching, and training to other employees within job area.
• 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.
• Collaborate with leadership on special projects as assigned.
• 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 input into desk level procedures, and precept new employees.
• Actively participate in staff meetings and huddles.

QUALIFICATIONS
Your Knowledge and Experience

• Previous experience in utilization management preferred
• Varied acute care clinical background
• Requires a current California RN License
• Requires a bachelor's degree or equivalent experience
• Strong computer skills related to Windows-based programs and applications
• Demonstrated ability to independently assess, evaluate, and interpret clinical information and care planning
• Excellent analytical and problem-solving skills
• 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
• Strong clinical documentation skills, independent problem identification and resolution skills
• Requires at least 7 years of prior relevant experience
• Working knowledge of regulatory and accreditation standards preferred (URAC, NCQA, DMHC, Case Management Society of America CMSA)

Pay Range:
The pay range for this role is: $ 109120.00 to $ 163680.00 for California.

Note:
Please note that this range represents the pay range for this and many other positions at Blue Shield that fall into this pay grade. Blue Shield salaries are based on a variety of factors, including the candidate's experience, location (California, Bay area, or outside California), and current employee salaries for similar roles.

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 truly 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 comprehensive approach to diversity, equity, and inclusion combines a focus on our people, processes, and systems with a deep commitment to promoting social justice and health equity through our products, business practices, and presence as a corporate citizen.

Blue Shield has received awards and recognition for being a certified Great Place to Work, best place to work for LGBTQ equality, leading disability employer, one of the best companies for women to advance, Bay Area’s top companies in volunteering & giving, and one of the world’s most ethical companies. Here at Blue Shield of California, we are striving to make a positive change across our industry and the communities we live in – join us!

Our Values:

• 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.
• 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.

Our Workplace Model:

Blue Shield of California is dedicated to making work-life balance a reality. Whether you prefer to work in an office or from home, we understand flexibility is more important than ever. That’s why Blue Shield is a hybrid company, offering you the opportunity to decide where you can do your best and most meaningful work.

Two ways of working: Hybrid (our default) and office

• Hybrid – In a business unit approved office a few times per year to 3 days per week, on average

• Office – In a business unit approved office 4+ days a week, on average. If the role you’re applying for is deemed an “Essential Role,” the company has determined that the role can only be performed in a Blue Shield office or in the field and would require your to meet the office worker classification.

Physical Requirements:

Office Environment - roles involving part to full time schedule in Office Environment. Due to the current public health emergency in California, Blue Shield employees are almost all working remotely. Based in our physical offices and work from home office/deskwork - Activity level: Sedentary, frequency most of work day.

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.

COVID-19 Vaccination Policy:

From the earliest days of the pandemic, Blue Shield of California has been unyielding in our commitment to putting the health and safety of our people, our members and our communities first. As a health care company, Blue Shield requires all employees to be up to date with COVID-19 vaccination prior to start date as a condition of employment. Blue Shield will consider requests for medical or religious accommodation to this vaccination requirement prior to your start date.

The definition of "up to date with your COVID-19 vaccine" is when you have received all doses in the primary series and one booster when eligible. If you are unable to be up to date with your COVID-19 vaccine by your start date, your start date will need to be postponed and you will have 30 days to remedy. If you cannot fulfill the requirement nor obtain accommodation within 30 days, your offer will be rescinded.