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Blue Shield of CA

Utilization Management Nurse, Senior (Prior Authorization)

Blue Shield of CA, Woodland Hills, California, us, 91371

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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 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 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