Senior Utilization Management Nurse - Hybrid/Remote

Blue Shield of CA; Los Angeles (CA); Hybrid; USD 95,000 - 120,000; Full time

Job summary

Blue Shield of CA is seeking a Utilization Management Concurrent Review Nurse in Los Angeles to review inpatient stays and apply evidence-based guidelines for authorization decisions. You will perform first-level determinations for Medicare, Medical, and Commercial plans, using clinical judgment and plan policies.

A CA RN license and strong communication skills are essential. The role emphasizes teamwork and independent motivation within a hybrid virtual work model, with opportunities for growth

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.

Responsibilities

• Reviews inpatient stays and applies guidelines for national levels of care.
• Performs first-level determination for authorization requests using guidelines and criteria.
• Reports to Utilization Management Nurse Manager and supports multiple plans.
• Assesses medical necessity and applies benefit plan knowledge to decisions.

Skills

Communication skills

Computer navigation skills

Teamwork

Independent motivation

Critical thinking

Education

Associate's degree in nursing

Bachelor of Science in Nursing

Job description

Blue Shield of CA is seeking a Utilization Management Concurrent Review Nurse in Los Angeles to review inpatient stays and apply evidence-based guidelines for authorization decisions. You will perform first-level determinations for Medicare, Medical, and Commercial plans, using clinical judgment and plan policies.

A CA RN license and strong communication skills are essential. The role emphasizes teamwork and independent motivation within a hybrid virtual work model, with opportunities for growth