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Utilization Management Nurse, Senior (Prior Authorization)
Blue Shield of CA - Oakland, California, United States, 94616 5 days ago
Your Role The Utilization Management Prior Authorization team accurate and timely prior authorization of designated healthcare services, continuity or...
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Utilization Management Nurse, Senior (Prior Authorization)
Blue Shield of CA - El Dorado Hills, California, United States, 95762 5 days ago
Your Role The Utilization Management Prior Authorization team accurate and timely prior authorization of designated healthcare services, continuity or...
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Senior UX Researcher
AAA Northern California, Nevada & Utah - Walnut Creek, California, United States, 94598 18 hours ago
Why Work For Us? Great Pay - opportunity to participate in AAA discretionary annual incentive plan or other incentive plans depending upon position 40...
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Go to next pageBlue Shield of CA - Oakland, California, United States, 94616
Work at Blue Shield of CA
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
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Utilization Management Nurse, Senior (Prior Authorization)