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Medicare Prior Authorization Nurse
1 month ago
At Blue Shield of California, we are seeking a skilled and experienced Medicare Prior Authorization RN to join our Utilization Management team. As a key member of our team, you will play a critical role in ensuring that our members receive high-quality, cost-effective care.
Key Responsibilities:- Conduct thorough reviews of prior authorization requests for medical necessity, coding accuracy, and medical policy compliance.
- Perform prospective, concurrent, and retrospective utilization reviews to ensure that our members receive the most appropriate care.
- Collaborate with our Medical Director to ensure that all determinations are made in accordance with state, federal, and accreditation requirements.
- Develop and review member-centered documentation and correspondence to ensure that all determinations are clearly communicated.
- Triage and prioritize cases to meet required turn-around times and ensure that our members receive timely access to care.
- Provide referrals to Case Management, Disease Management, Appeals and Grievance, and Quality Departments as necessary.
- Attend staff meetings, clinical rounds, and weekly huddles to stay informed and collaborate with colleagues.
- Maintain quality and productivity metrics for all casework.
- Ensure a HIPAA-compliant workspace for telework environments.
- Bachelor's of Science in Nursing or advanced degree preferred.
- Health plan experience preferred.
- Prior authorization experience preferred.
We offer a competitive salary and benefits package, as well as opportunities for professional growth and development. If you are a motivated and detail-oriented RN with a passion for delivering high-quality care, we encourage you to apply for this exciting opportunity.
