Hybrid Utilization Management Nurse – Concurrent Review

Blue Shield of CA; Redding (CA); Híbrido; USD 110.000 - 140.000; Jornada completa

Descripción de la vacante

Blue Shield of California is seeking an Utilization Management Concurrent Review Nurse. The role performs first level determinations for authorization requests using evidence-based guidelines and nationally recognized criteria across Medicare, Medical, and Commercial plans.

Strong clinical judgment and knowledge of benefit plans are essential. This position supports hybrid virtual work with occasional office visits based on business needs.

Formación

• Must hold an active, unrestricted CA RN license.
• Associate's degree in nursing is required.
• Bachelor of Science in Nursing is preferred.
• Requires at least 5 years of prior relevant experience.
• Requires strong communication and computer navigation skills.
• Desires strong teamwork and collaboration skills.
• Requires independent motivation and strong work ethic.
• Requires strong critical thinking skills.

Responsabilidades

• Performs first level determination for authorization requests using BSC evidence-based guidelines, policies, and nationally recognized criteria.
• Conducts reviews for authorization requests based on medical necessity and clinical judgment.
• Applies knowledge of benefit plans to complete review decisions.
• Collaborates with Utilization Management team and reports to Nurse Manager.

Educación

Associate's degree in nursing

Bachelor of Science in Nursing (preferred)

Descripción del empleo

Blue Shield of California is seeking an Utilization Management Concurrent Review Nurse. The role performs first level determinations for authorization requests using evidence-based guidelines and nationally recognized criteria across Medicare, Medical, and Commercial plans.

Strong clinical judgment and knowledge of benefit plans are essential. This position supports hybrid virtual work with occasional office visits based on business needs.