Utilization Management Nurse, Senior- Prior Authorization

Blue Shield of California • Rancho Cordova, CA

1d • Hybrid

About The Position

Your Role The Utilization Management Prior Authorization team does 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 of 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 Commercial and FEP. 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. Our leadership model is about developing great leaders at all levels and creating opportunities for our people to grow – personally, professionally, and financially. We are looking for leaders that are energized by creative and critical thinking, building and sustaining high-performing teams, getting results the right way, and fostering continuous learning. Responsibilities Your Work In this role, you will: Perform prospective 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 BSC Commercial and FEP Ensure discharge (DC) planning at levels of care appropriate for the members needs and acuity and determine post-acute needs of members 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 Other duties as assigned Qualifications Your Knowledge and Experience Requires a bachelor's degree or equivalent experience Requires a current California RN License Requires at least 5 years of prior relevant experience Requires practical knowledge of job area typically obtained through advanced education combined with experience Experience working with or for a manage health care plan preferred Experience with Commercial managed care plans preferred Effective time management skills and ability to define and act on priorities efficiently preferred Excellent communication skills both orally and in writing with all levels of BSC staff, members, contracted physicians, and participating provider groups preferred Hybrid Virtual Work This role allows employees to work virtually full-time, however employees will be expected to come to the office based on business need.

Requirements

• Requires a bachelor's degree or equivalent experience
• Requires a current California RN License
• Requires at least 5 years of prior relevant experience
• Requires practical knowledge of job area typically obtained through advanced education combined with experience

Nice To Haves

• Experience working with or for a manage health care plan preferred
• Experience with Commercial managed care plans preferred
• Effective time management skills and ability to define and act on priorities efficiently preferred
• Excellent communication skills both orally and in writing with all levels of BSC staff, members, contracted physicians, and participating provider groups preferred

Responsibilities

• Perform prospective 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 BSC Commercial and FEP
• Ensure discharge (DC) planning at levels of care appropriate for the members needs and acuity and determine post-acute needs of members 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
• Other duties as assigned

What This Job Offers

• Job Type: Full-time
• Career Level: Senior
• Number of Employees: 1-10 employees