Senior Inpatient Utilization Management Nurse

Blue Shield of CA; Long Beach (CA); Hybrid; USD 95,000 - 125,000; Full time

Job summary

Blue Shield of California is seeking an Utilization Management Concurrent Review Nurse to review inpatient stays for our members and apply evidence-based guidelines to determine medical necessity. You will report to the Utilization Management Nurse Manager and perform first level determinations for authorization requests across Medicare, Medical, or Commercial plans.

This role supports a hybrid virtual work model with occasional in-office meetings; the ideal candidate holds an active CA RN

Qualifications

• Active, unrestricted CA RN license.
• Associate's degree in nursing is required.
• Bachelor of Science in Nursing is preferred.
• At least 5 years of prior relevant experience.
• Strong communication and computer navigation skills.
• Strong teamwork and collaboration skills.
• Independent motivation and strong work ethic.
• Strong critical thinking skills.

Responsibilities

• Review inpatient stays and authorize requests based on evidence-based guidelines and medical necessity.
• Apply nationally recognized criteria across Medicare, Medical, or Commercial plans and document decisions.

Skills

Communication skills

Teamwork / Collaboration

Independent motivation

Critical thinking

Computer navigation skills

Education

Associate's degree in nursing

Bachelor of Science in Nursing

Job description

Blue Shield of California is seeking an Utilization Management Concurrent Review Nurse to review inpatient stays for our members and apply evidence-based guidelines to determine medical necessity. You will report to the Utilization Management Nurse Manager and perform first level determinations for authorization requests across Medicare, Medical, or Commercial plans.

This role supports a hybrid virtual work model with occasional in-office meetings; the ideal candidate holds an active CA RN