Your Role

The Utilization Management Prior Authorization team processes 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 Medicare. Successful RN candidate reviews prior auth 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 Work

In this role, you will:

• Perform prospective, concurrent and retrospective 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 Medicare
• Conducts clinical review of claims for medical necessity, coding accuracy, medical policy compliance and contract compliance
• Ensure 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 planning
• Prepare 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 requirements
• Develop 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 appropriate
• Triages and prioritizes cases to meet required turn-around times and expedites access to appropriate care for members with urgent needs
• Provides referrals to Case Management, Disease Management, Appeals and Grievance and Quality Departments, as necessary
• Attend staff meetings, clinical rounds and weekly huddles
• Maintain quality and productivity metrics for all casework
• Maintaining HIPAA compliant workspace for telework environment
• Other duties as assigned

Your Knowledge and Experience

• Bachelors of Science in Nursing or advanced degree preferred
• 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
• Health plan experience preferred
• Prior Authorization experience preferred
• Requires strong written and oral communication skills
• Strong analytical and problem-solving skills
• Strong teamwork and collaboration skills
• Independent motivation and strong work ethic

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.