Utilization Management Nurse, Senior (Prior Auth)

Your RoleThe 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 WorkIn 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 MedicareConducts clinical review of claims for medical necessity, coding accuracy, medical policy compliance and contract complianceEnsure 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 planningPrepare 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 requirementsDevelop 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 appropriateTriages and prioritizes cases to meet required turn-around times and expedites access to appropriate care for members with urgent needsProvides referrals to Case Management, Disease Management, Appeals and Grievance and Quality Departments, as necessaryAttend staff meetings, clinical rounds and weekly huddlesMaintain quality and productivity metrics for all caseworkMaintaining HIPAA compliant workspace for telework environmentOther duties as assignedYour Knowledge and Experience

Bachelors of Science in Nursing or advanced degree preferredRequires a current California RN LicenseRequires at least 5 years of prior relevant experienceRequires practical knowledge of job area typically obtained through advanced education combined with experienceHealth plan experience preferredPrior Authorization experience preferredRequires strong written and oral communication skillsStrong analytical and problem-solving skillsStrong teamwork and collaboration skillsIndependent motivation and strong work ethic

Pay Range:The pay range for this role is: $ 87230.00 to $ 130900.00 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.