Your Role
The Utilization Management team manages accurate and timely prior authorization and inpatient stays reviews for our members and correctly applies the guidelines for nationally recognized levels of care for our Shared Services department including concurrent review, transplant and NICU/HROB. The Utilization Management Nurse, Consultant will report to the Manager, Utilization and Medical Review. In this role you will be supporting the department by supporting the clinicians who perform 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, Medi-Cal or Medicare. Successful RN candidate reviews authorization 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. The Utilization Management Nurse, Consultant will support the department operations by assisting with case review, auditing, responding to inquiries, training, and system testing.
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
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.
Utilization Management Nurse, Senior • Oakland, CA, United States
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