Utilization Care Manager Staff

Looking for a chance to do meaningful work that touches millions? Come join the hardest working, nonprofit health plan in California and help us shape the future of health care. Blue Shield of California's Mission is to ensure all Californians have access to high-quality care at an affordable price. Blue Shield is focused on improving health care delivery by working closely with providers and making it more accessible, affordable and customer-centric. Being a mission-driven organization means we do much more than serve our 4 million members: we were the first health plan in the nation to limit our annual net income to 2 percent of revenue and return the difference to our customers and the community, and since 2005 we have contributed more than $325 million to the Blue Shield of California Foundation to improve community health and end domestic violence. We also believe that a healthier California begins with our employees, so we provide them with resources to develop and maintain a healthy lifestyle through our award-winning wellness program, Wellvolution. We're hiring smart thinkers and doers who want to work for a leader and innovator in the challenging, ever-changing healthcare space. Come and help us make health care better for everyone. Description Performs advanced or complicated case review and determines first level approvals for prior authorization of services, inpatient, outpatient and/or ancillary services. The review process requires interpretation and application of evidenced based criteria as established by Blue Shield of California (BSC) medical policy and other approved resources. Clinical judgment and detailed knowledge of benefit plans used to complete review decisions. Acts as liaison between the member, the provider and the health plan to utilize appropriate and cost effective resources. Ultimate goal is Discharge (DC) planning and to return patient to cognitive and physical condition prior to event that triggered treatment. Responsibilities Performs 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. Ensures diagnosis matches ICD9 codes. Conduct UM/care management (CM) review activities with delegated entities as necessary. Manages member treatment in order to meet Recommended Length of Stay. Ensures discharge(DC) planning at levels of care appropriate for the members needs and acuity. Determines discharge (DC) plan by assessing cognitive and physical status. Determines post-acute needs of patient, levels of care, equipment, how event is going to impact patients status. Ensures quality, cost-effective DC planning. Triages and prioritizes cases to meet required turn-around times. Expedites access to appropriate care for members with urgent needs using expedited review process. Prepares and presents cases to Medical Director (MD) as required by law for medical necessity determination. Communicate determinations to providers and/or members to in compliance with state, federal and accreditation requirements. Develops and reviews member centered documentation and correspondence reflecting determinations in compliance with regulatory and accreditation standards. Identifies potential quality of care issues, service or treatment delays and intervenes or as clinically appropriate. Provides 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. Manages multiple complex cases including lower level of care. Supports Lead UM Care manager including precepting, audits and special projects. Acts as resource and educator for colleagues. Qualifications Education/Requirements: Current Active CA RN License. Bachelors of Science Degree in Nursing preferred. Proficient knowledge of NCQA, URAC, federal and state requirements. Knowledge of Coordination of Care, Medicare regulations, prior authorization, level of care and length of stay criteria sets desirable. Demonstrates professional judgment, and critical thinking, to promote the delivery of quality, cost-effective care. This judgment is based on medical necessity including intensity of service and severity of illness within contracted benefits and appropriate level of care. Education, skills, knowledge and competencies as defined for the Int. UM Care Manager. Demonstrated and evolving competence in UM functions and understanding of BSC book of business. Proficient in program operations and metrics. Minimum Experience Level: Requires extensive experience in nursing, 3-4 years acute clinical experience and 3 years utilization management preferred. Supervisory responsibilities: Monitors Clinical Support Coordinators (non-clinical) in the performance of UM support activities, Quality assurance and regular performance audits. Training and mentoring backup to Lead as needed. #J-18808-Ljbffr Blue Shield of California