Senior Utilization Management Nurse — Hybrid, Clinical Review

Blue Shield of CA; Lodi (CA); Hybrid; USD 90,000 - 120,000; Full time

Job summary

Blue Shield of California seeks an Utilization Management Concurrent Review Nurse to perform first level determinations for authorization requests using evidence-based guidelines and nationally recognized criteria. The role reviews medical necessity and clinical judgment for Medicare, Medical, or Commercial plans, while aligning with benefit plans and internal policies.

The position reports to the Utilization Management Nurse Manager and supports high-performing teams.

Qualifications

• 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.

Skills

CA RN license

communication skills

computer navigation

teamwork

independent motivation

strong work ethic

critical thinking

Education

Associate's degree in nursing

Bachelor of Science in Nursing (preferred)

Job description

Blue Shield of California seeks an Utilization Management Concurrent Review Nurse to perform first level determinations for authorization requests using evidence-based guidelines and nationally recognized criteria. The role reviews medical necessity and clinical judgment for Medicare, Medical, or Commercial plans, while aligning with benefit plans and internal policies.

The position reports to the Utilization Management Nurse Manager and supports high-performing teams.