Utilization Management Nurse, Senior
About The Position
The Utilization Management team manages accurate and timely prior authorization and inpatient stays reviews for members, applying guidelines for nationally recognized levels of care for the Shared Services department, including concurrent review, transplant, and NICU/HROB. The Utilization Management Nurse, Senior supports the department by assisting clinicians with first-level determination approvals for members, utilizing BSC evidenced-based guidelines, policies, and nationally recognized clinical criteria across various lines of business (Commercial, Medi-Cal, Medicare). This role involves reviewing authorization requests for medical necessity, coding accuracy, and medical policy compliance, requiring clinical judgment and detailed knowledge of benefit plans. The Senior Nurse also supports department operations through case review, auditing, inquiry response, training, and system testing. Blue Shield of California, a subsidiary of Ascendiun as of January 2025, is a nonprofit corporate entity focused on creating a healthcare system worthy of family and friends and sustainably affordable. The company aims to lower costs, improve quality, and enhance member and physician experience, fostering an environment where employees can thrive. Blue Shield is recognized as a U.S. News Best Company to work for, a Deloitte U.S. Best Managed Company, a Top 100 Inspiring Workplace, a Top Regional Company by Fair360, and one of the 50 most community-minded companies by Points of Light. The company values honesty, humanity, and courage.
Requirements
- Successful RN candidate
- Clinical judgment and detailed knowledge of benefit plans used to complete review decisions is required
- External hires must pass a background check/drug screen
Responsibilities
- Support the clinicians who perform 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, Medi-Cal or Medicare
- Review authorization requests for medical necessity, coding accuracy and medical policy compliance
- Assist with case review
- Assist with auditing
- Assist with responding to inquiries
- Assist with training
- Assist with system testing
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What This Job Offers
Job Type
Full-time
Career Level
Senior
Education Level
No Education Listed
Number of Employees
1-10 employees
