Utilization Management Nurse, Senior

Blue Shield of California•Rancho Cordova, CA

3d•$90,860 - $153,636•Hybrid

About The Position

The Utilization Management team manages accurate and timely prior authorization and inpatient stays reviews for our members and correctly applies the guidelines for nationally recognized levels of care for our Shared Services department including concurrent review, transplant and NICU/HROB. The Utilization Management Nurse, Senior will report to the Manager, Utilization and Medical Review. In this role you will be supporting the department by supporting 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. Successful RN candidate reviews authorization 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. The Utilization Management Nurse, Senior will support the department operations by assisting with case review, auditing, responding to inquiries, training, and system testing. 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.

Requirements

Registered Nurse (RN) candidate
Clinical judgment
Detailed knowledge of benefit plans
Ability to support department operations by assisting with case review, auditing, responding to inquiries, training, and system testing.

Nice To Haves

Experience in creative and critical thinking
Experience in building and sustaining high-performing teams
Experience in getting results the right way
Experience in fostering continuous learning

Responsibilities

Manage accurate and timely prior authorization and inpatient stays reviews for members.
Apply guidelines for nationally recognized levels of care for the Shared Services department, including concurrent review, transplant, and NICU/HROB.
Support clinicians performing first-level determination approvals using BSC evidenced-based guidelines, policies, and nationally recognized clinical criteria.
Review authorization requests for medical necessity, coding accuracy, and medical policy compliance.
Utilize clinical judgment and detailed knowledge of benefit plans to complete review decisions.
Assist with case review, auditing, responding to inquiries, training, and system testing to support department operations.