Utilization Management Nurse, Senior (Prior Authorization)

Job Description

Your Role

The 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.

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 Promise Medi-Cal and MedicareEnsure 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 necessaryOther duties as assignedQualifications

Your Knowledge and Experience

Requires 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 preferredPay 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.

About the Team

Blue Shield of California's mission is to ensure all Californians have access to high-quality health care at a sustainably affordable price. We are transforming health care in a way that genuinely serves our nonprofit mission by lowering costs, improving quality, and enhancing the member and physician experience.

To fulfill our mission, we must ensure a diverse, equitable, and inclusive environment where all employees can be their authentic selves and fully contribute to meet the needs of the multifaceted communities we serve. Our continued commitment to diversity, equity, and inclusion upholds our values and advances our goal of creating a healthcare system that is worthy of our family and friends while addressing health disparities, promoting social justice, and integrating health equity through our products, business practices, and presence as a corporate citizen.

Blue Shield has received awards and recognition for being a certified Fortune 100 Best Companies to Work, Military Friendly Employer, People Companies that Care, a Leading Disability Employer, and one of California's top companies in volunteering and giving. Here at Blue Shield, we strive to make a positive change across our industry and communities - join us!

Our Values :

Honest . We hold ourselves to the highest ethical and integrity standards. We build trust by doing what we say we're going to do and by acknowledging and correcting where we fall short.Human . We strive to be our authentic selves, listening and communicating effectively, and showing empathy towards others by walking in their shoes.Courageous . We stand up for what we believe in and are committed to the hard work necessary to achieve our ambitious goals.Our Workplace Model :

At Blue Shield of California, we believe in fostering a workplace environment that balances purposeful in-person collaboration with flexibility. As we continue to evolve our workplace model, our focus remains on creating spaces where our people can connect with purpose - whether working in the office or through a hybrid approach - by providing clear expectations while respecting the diverse needs of our workforce.

Two Ways of Working :

Hybrid (Default) :

Work from a business unit-approved office at least two (2) times per month (for roles below Director-level) or once per week (for Director-level roles and above).Exceptions : Member-facing and approved out-of-state roles remain remote.Employees living more than 50 miles from their assigned offices are expected to work with their managers on a plan for periodic office visits.For employees with medical conditions that may impact their ability to work in-office, we are committed to engaging in an interactive process and providing reasonable accommodations to ensure their work environment is conducive to their success and well-being.

On-Site :

Work from a business unit-approved

office

an average of four (4) or more days a week.

Physical Requirements :

Office Environment - roles involving part to full time schedule in Office Environment. Based in our physical offices and work from home office / deskwork - Activity level : Sedentary, frequency most of work day.

Please click here for further physical requirement detail.

Equal Employment Opportunity :

External hires must pass a background check / drug screen. Qualified applicants with arrest records and / or conviction records will be considered for employment in a manner consistent with Federal, State and local laws, including but not limited to the San Francisco Fair Chance Ordinance. All qualified applicants will receive consideration for employment without regards to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran status or disability status and any other classification protected by Federal, State and local laws.

Salary : $87,230 - $130,900