Senior Utilization Management Nurse – Hybrid/Remote

Blue Shield of CA; Oakland (CA); Hybrid; USD 110,000 - 140,000; Full time

Job summary

Blue Shield of CA is seeking a Utilization Management Concurrent Review Nurse to perform first level determinations for authorization requests under evidence-based guidelines. You will assess medical necessity using policy and clinical judgment across Medicare, Medical, and Commercial plans.

The role emphasizes leadership development and collaboration within high-performing teams, with hybrid virtual work requiring occasional in-office presence as needed.

Qualifications

• Active, unrestricted CA RN license.
• Associate's degree in nursing is required.
• Bachelor of Science in Nursing is preferred.
• Minimum 5 years of relevant experience.
• Strong communication and computer navigation skills.

Responsibilities

• Perform first level determination for authorization requests using guidelines and policies.
• Review for medical necessity and clinical judgment to authorize care.
• Collaborate with the Utilization Management team to ensure consistent decisions.

Skills

Communication

Computer navigation

Teamwork

Independent motivation

Critical thinking

Education

Associate degree in Nursing

BSN preferred

Job description

Blue Shield of CA is seeking a Utilization Management Concurrent Review Nurse to perform first level determinations for authorization requests under evidence-based guidelines. You will assess medical necessity using policy and clinical judgment across Medicare, Medical, and Commercial plans.

The role emphasizes leadership development and collaboration within high-performing teams, with hybrid virtual work requiring occasional in-office presence as needed.