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.

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 Medi-Cal managed care including Medicare 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 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.