The Utilization Management Clinician provides utilization management (such as prospective concurrent and retrospective review) to best meet the member's specific healthcare needs and to promote quality and cost-effective outcomes and appropriate payment for services.
The Utilization Management Clinician is responsible for review in one or more of the following areas: prospective: Utilization management conducted prior to a patient's admission, stay, or other service or course of treatment (including outpatient procedures and services). Sometimes called "precertification review" or "prior authorization," prospective review can include prospective prescription drug utilization review.; concurrent: Utilization management conducted during a patient's hospital stay or course of treatment (including outpatient procedures and services). Sometimes called "continued stay review".
Retrospective: Review conducted after services (including outpatient procedures and services) have been provided to the patient.
Applies clinical expertise and judgment to ensure compliance with medical policy, medical necessity guidelines, and accepted standards of care. Utilizes evidence-based criteria that incorporates current and validated clinical research findings. Practices within the scope of their license.
Consults with physician advisors to ensure clinically appropriate determinations.
May facilitate transitions of care through collaboration with the member, the facilities interdisciplinary team and Regence's Case Management to achieve optimal recovery for the member.
Serves as a resource to internal and external customers.
Collaborates with other departments to resolve claims, quality of care, member or provider issues.
Identifies problems or needed changes, recommends resolution, and participates in quality improvement efforts.
Responds in writing, by phone, or in person to members, providers and regulatory organizations in a professional manner while protecting confidentiality of sensitive documents and issues.
Provides consistent and accurate documentation.
Plans, organizes and prioritizes assignments to comply with performance standards, corporate goals, and established timelines.
Knowledge of health insurance industry trends, technology and contractual arrangements.
General computer skills (including use of Microsoft Office, Outlook, internet search). Familiarity with health care documentation systems.
Strong verbal, written and interpersonal communication and customer service skills.
Ability to interpret policies and procedures and communicate complex topics effectively.
Strong organizational and time management skills with the ability to manage workload independently.
Ability to think critically and make decisions within individual role and responsibility.
Normally to be proficient in the competencies listed above
Utilization Management Nurse would have a/an Associate or Bachelor's Degree in Nursing or related field and 3 years of case management, utilization management, disease management, auditing or retrospective review experience or equivalent combination of education and experience.
Required Licenses, Certifications, Registration, Etc.
Must have a current unrestricted RN license and at least 3 years (or full time equivalent) of direct clinical care.
Regence employees are part of the larger Cambia family of companies, which seeks to drive innovative health solutions. We offer a competitive salary and a generous benefits package. Regence is 2.2 million members, here for our families, co-workers and neighbors, helping each other be and stay healthy and provide support in time of need. We've been here for members for 100 years. Regence is a nonprofit health care company offering individual and group medical, dental, vision and life insurance, Medicare and other government programs as well as pharmacy benefit management. We are the largest health insurer in the Northwest/Intermountain Region, serving members as Regence BlueShield of Idaho, Regence BlueCross BlueShield of Oregon, Regence BlueCross BlueShield of Utah and Regence BlueShield (in Washington). Each plan is an independent licensee of the Blue Cross and Blue Shield Association.
If you're seeking a career that affects change in the health care system, consider joining our team at Cambia Health Solutions. We advocate for transforming the health care system by making health care more affordable and accessible, increasing consumers' engagement in their health care decisions, and offering a diverse range of products and services that promote the health and well-being of our members. Cambia's portfolio of companies spans health care information technology and software development; retail health care; health insurance plans that carry the Blue Cross and Blue Shield brands; pharmacy benefit management; life, disability, dental, vision and other lines of protection; alternative solutions to health care access and free-standing health and wellness solutions.
We are an Equal Opportunity and Affirmative Action employer dedicated to workforce diversity and a drug and tobacco-free workplace. All qualified applicants will receive consideration for employment without regard to race, color, national origin, religion, age, sex, sexual orientation, gender identity, disability, protected veteran status or any other status protected by law. A drug screen and background check are required.