Prior Authorization Specialist RN

About the Prior Authorization Team Lead PositionThe Prior Authorization Team Lead is responsible for leading a high-performing team that ensures accurate and timely prior authorization of designated healthcare services. This includes establishing operational objectives, collaborating with other managers, and ensuring regulatory and accreditation standards...

Job OverviewWe are seeking an experienced Registered Nurse to join our Utilization Management team as a Senior Utilization Management Nurse. This role plays a critical part in the timely authorization of healthcare services, ensuring compliance with medical necessity and quality of care standards.About the RoleThe Senior Utilization Management Nurse will...

Key ResponsibilitiesPerform prospective utilization reviews and first-level determination approvals for members using evidence-based guidelines, policies, and nationally recognized clinical criteria.Ensure discharge planning at levels of care appropriate for members' needs and acuity, and determine post-acute needs, including levels of care, durable medical...

RequirementsBachelor's degree or equivalent experienceCurrent California RN LicenseAt least 10 years of prior relevant experience including 4 years of management experienceKnowledge of regulatory requirements for all Lines of Business (Medi-Cal, ASO/SA, IFP, Medicare Advantage)Practical knowledge in leading and managing the execution of processes, projects...

Job OverviewThe Manager of Utilization Management Nurse Management plays a pivotal role in ensuring the effective and timely approval of healthcare services. As a leader, this position oversees daily operations, process improvements, and budget development while fostering high-performing teams and upholding regulatory standards.About the RoleThis key...

Overview of the RoleThe Blue Shield Clinical Service Coordinator Advanced will support clinical staff in day-to-day operations for Promise (Medi-Cal) and Commercial/Medicare lines of business. In this role, you will be responsible for timely and accurate processing of Treatment Authorization Requests.Your ResponsibilitiesWork in a production-based...

About the RoleThis is a senior-level position in our Utilization Management team. The Utilization Management Nurse, Senior Specialist will play a critical role in ensuring accurate and timely prior authorization of designated healthcare services.Key ResponsibilitiesPerform prospective utilization reviews and first-level determination approvals for members...

About the RoleThe Utilization Management Nurse, Senior will be responsible for ensuring the accurate and timely prior authorization of designated healthcare services. This professional will report to the Manager, Utilization and Medical Review, and be responsible for performing first-level determination approvals for members using BSC evidence-based...

About the Role As a Clinical Services Coordinator at Blue Shield of California, you will be responsible for supporting clinical staff in day-to-day operations. This includes processing Treatment Authorization Requests and working in a production-based environment with defined production and quality metrics. Your Responsibilities In this role, you...

Job SummaryWe are seeking a highly skilled and experienced Utilization Management Nurse, Senior to join our team at Blue Shield of California. As a key member of our prior authorization team, you will play a critical role in ensuring timely and accurate approval of healthcare services for our members.In this role, you will be responsible for performing...

Job Title: RN Care Management Professional**Job Description:** Blue Shield of California is seeking an experienced RN to join our Care Management team as a RN Care Management Professional. In this role, you will be responsible for performing first-level determination approvals, reviewing prior authorization requests, and developing member-centered...

About the RoleThe Medical Care Solutions education team is responsible for all clinical education across various departments. This includes Utilization Management, Care Management, Post Service, and Appeals.This role will be responsible for facilitating clinical education and supporting Utilization Management for all lines of business.Key...

Job Summary:We are seeking a highly skilled Indemnity Specialist to join our team at Tristar Insurance. This is a full-time position that requires excellent analytical skills, effective management of complex claims, and strong communication skills.The ideal candidate will have a bachelor's degree in a related field or equivalent experience. Certifications...

About the RoleWe are seeking a talented RN to join our Utilization Management Prior Authorization team. In this role, you will be responsible for reviewing prior authorization requests, performing prospective utilization reviews, and ensuring accurate and timely discharge planning. You will also work closely with Medical Directors to ensure that...

Job Title: Healthcare Utilization Manager**Overview:** Blue Shield of California is seeking a highly skilled RN to join our Utilization Management team. As a Healthcare Utilization Manager, you will play a crucial role in ensuring timely and accurate prior authorization of designated healthcare services.Estimated Salary: $85,000 - $110,000 per...

About the Role:We are seeking a highly skilled Healthcare Utilization Specialist to join our team at Blue Shield of California. As a member of our Utilization Management department, you will play a critical role in reviewing inpatient stays for our members and applying nationally recognized levels of care guidelines.This position requires strong analytical...

Job Description:We are seeking a seasoned professional to fill the role of Utilization Management Lead at Blue Shield of California. This position will be responsible for overseeing the Utilization Management Prior Authorization team, ensuring timely and accurate prior authorization of designated healthcare services.The ideal candidate will possess a...

Job OverviewThe Clinical Review Specialist, Senior performs in-depth clinical analysis of outpatient claims to assess medical necessity and compliance with established standards. This role involves collaboration with medical directors to ensure adherence to evidence-based guidelines.Your Key ResponsibilitiesPerform retrospective utilization reviews and...

Job OverviewWe are seeking a skilled Clinical Review Specialist to join our Medi-Cal Appeals and Grievances team. This role involves performing accurate and timely clinical reviews of member appeals and grievances, ensuring compliance with National Coverage Determination (NCD) guidelines and other relevant regulations.The successful candidate will have...

About the RoleWe are looking for a skilled Complex Claims Specialist to join our team at Tristar Insurance. As a key member of our claims team, you will be responsible for managing complex and litigated indemnity claims from inception to conclusion within established authority and guidelines.ResponsibilitiesEffectively manage a caseload of indemnity claim...