Utilization Management Nurse, Senior (NICU)

Your Role

The Utilization Management team reviews inpatient stays for our members and correctly applies the guidelines for nationally recognized levels of care for our Shared Services departments including concurrent review, transplant, and NICU/HROB. 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 Medicare 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.

Your Knowledge and Experience

• Bachelors of Science in Nursing or advanced degree preferred

• 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 in NICU/HROB