Senior Utilization Management Nurse — Remote/Hybrid

Blue Shield of California; California (MO); Hybrid; USD 91,000 - 136,000; Full time

Benefits offered by this job

Hybrid work model

Job summary

Blue Shield of California is seeking an experienced Utilization Management RN to manage complex prospective, concurrent, and retrospective reviews across multiple lines of business. The role ensures medical necessity, coding accuracy, and effective discharge planning while supporting policy compliance and process improvement.

Applicants must hold an Associate Degree in Nursing and have 5 years of relevant managed care or clinical experience, with an active RN license in assigned states or

Qualifications

• Associate Degree in Nursing is required.
• Bachelor of Science in Nursing or advanced degree is preferred.
• 5 years of prior relevant experience in managed care environment or clinical setting.
• Active, unrestricted RN license in assigned states or ability to obtain required state license within 90 days of hire.

Responsibilities

• Independently manages complex prospective, concurrent, and retrospective utilization reviews across multiple lines of business.
• Conducts retrospective clinical reviews of claims for medical necessity, coding accuracy, medical policy, and contract compliance.
• Serves as a clinical subject matter resource to peers by providing guidance on criteria application, documentation, and processes.
• Evaluates treatment plans, lengths of stay, and discharge planning to ensure quality, cost effective utilization of services.
• Identifies overpayment, third party liability, and coordination of benefits opportunities and initiates appropriate follow up.
• Supports process improvement efforts to enhance clinical consistency, efficiency, and regulatory compliance.
• Escalates complex or high risk cases to leadership or Medical Directors with clear clinical rationale.
• Works with minimal supervision while maintaining accountability for quality, accuracy, and timeliness.
• Ability to work evenings and weekends as part of rotating on-call schedule.

Education

Associate Degree in Nursing

Bachelor of Science in Nursing or advanced degree (preferred)

Job description

Blue Shield of California is seeking an experienced Utilization Management RN to manage complex prospective, concurrent, and retrospective reviews across multiple lines of business. The role ensures medical necessity, coding accuracy, and effective discharge planning while supporting policy compliance and process improvement.

Applicants must hold an Associate Degree in Nursing and have 5 years of relevant managed care or clinical experience, with an active RN license in assigned states or