Blue Shield
Utilization Management Nurse, Senior (Prior Auth)
Blue Shield, Baltimore, Maryland, United States,
Your Role
The Utilization Management Prior Authorization team processes accurate and timely prior authorization of designated healthcare services, continuity or care, and access to care clinical review determinations. 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. 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
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
Triages and prioritizes cases to meet required turn-around times and expedites access to appropriate care for members with urgent needs
Provides referrals to Case Management, Disease Management, Appeals and Grievance and Quality Departments, as necessary
Attend staff meetings, clinical rounds and weekly huddles
Maintain quality and productivity metrics for all casework
Maintaining HIPAA compliant workspace for telework environment
Other duties as assigned
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The Utilization Management Prior Authorization team processes accurate and timely prior authorization of designated healthcare services, continuity or care, and access to care clinical review determinations. 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. 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
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
Triages and prioritizes cases to meet required turn-around times and expedites access to appropriate care for members with urgent needs
Provides referrals to Case Management, Disease Management, Appeals and Grievance and Quality Departments, as necessary
Attend staff meetings, clinical rounds and weekly huddles
Maintain quality and productivity metrics for all casework
Maintaining HIPAA compliant workspace for telework environment
Other duties as assigned
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