Utilization Management Nurse, Senior (Prior Authorization)

Your RoleThe Utilization Management Prior Authorization team 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 Medi-Cal and Medicare. Successful RN candidate reviews prior 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.Your Knowledge and ExperienceRequires a bachelor's degree or equivalent experienceRequires 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 experienceExperience working with or for a manage health care plan preferredExperience with Medi-Cal managed care including Medicare preferredEffective time management skills and ability to define and act on priorities efficiently preferredExcellent communication skills both orally and in writing with all levels of BSC Promise staff, members, contracted physicians, and participating provider groups preferred

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.

Salary : $87,230 - $130,900