Job Description

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 Work 

In this role, you will: 

• Perform prospective 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 BSC Promise Medi-Cal and Medicare 
• 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
• Other duties as assigned

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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