Senior RN, Utilization Management — Hybrid Review Leader

Blue Shield of CA; Springfield Meadows (CA); Hybrid; USD 90.000 - 115.000; Vollzeit

Zusammenfassung

Blue Shield of CA is seeking an Utilization Management Concurrent Review Nurse to perform first-level determinations for authorization requests. You will apply evidence-based guidelines and national criteria across Medicare, Medical and Commercial plans, supporting medical necessity decisions with clinical judgment.

You must have a CA RN license and a nursing degree; 5+ years of experience and strong communication, teamwork, and critical thinking are essential.

Qualifikationen

• Must maintain 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.

Aufgaben

• Perform first-level determination for authorization requests using evidence-based guidelines.
• Review for medical necessity and clinical judgment across Medicare, Medical, or Commercial plans.
• Collaborate with Utilization Management team and report to the Nurse Manager.
• Maintain knowledge of benefit plans and relevant policies.

Kenntnisse

Communication skills

Computer navigation

Teamwork

Independent motivation

Critical thinking

Ausbildung

Associate's degree in nursing

Bachelor of Science in Nursing

Jobbeschreibung

Blue Shield of CA is seeking an Utilization Management Concurrent Review Nurse to perform first-level determinations for authorization requests. You will apply evidence-based guidelines and national criteria across Medicare, Medical and Commercial plans, supporting medical necessity decisions with clinical judgment.

You must have a CA RN license and a nursing degree; 5+ years of experience and strong communication, teamwork, and critical thinking are essential.