Utilization Management Nurse, Senior- Prior Authorization

Your Role

The Utilization Management Prior Authorization team does 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 of 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 Commercial and FEP. 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.

Our leadership model is about developing great leaders at all levels and creating opportunities for our people to grow - personally, professionally, and financially. We are looking for leaders that are energized by creative and critical thinking, building and sustaining high-performing teams, getting results the right way, and fostering continuous learning.

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 Commercial managed care plans 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 staff, members, contracted physicians, and participating provider groups preferred

Hybrid Virtual Work

This role allows employees to work virtually full-time, however employees will be expected to come to the office based on business need.