Utilization Management Nurse, Senior

Your Role

The Utilization Management team reviews the inpatient stays for our members and correctly applies the guidelines for nationally recognized levels of care. The Utilization Management Nurse will report to the Utilization Management Nurse Manager. In this role you will be assigned a list of inpatient facilities and then review clinical information provided by the facilities to determine medical necessity when our members admit. You will also be involved with discharge planning and transfers as needed for higher levels of care or out of network admissions.

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

• Conducts 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 member 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

• Refer to Case Management when there are acute inpatient needs affecting discharge

• Attend staff meetings, clinical rounds and weekly huddles

• Maintain quality and productivity metrics for all casework

• Buddy or support new employees

• Maintaining HIPAA compliant workspace for telework environment