Utilization Management Nurse, Senior

Blue Shield of CA; Oakland (CA); Hybrid; USD 120,000 - 180,000; Full time

Job summary

Blue Shield of California is seeking a nurse leader to oversee Utilization Management, coordinating complex reviews across lines of business and ensuring medical necessity, coding accuracy, and appropriate discharge planning.

You will work in a hybrid virtual role, with on-site requirements as needed, maintain RN licensure, and mentor teams to improve quality and timeliness while escalating high-risk cases as required. The position is based in Oakland, CA.

Qualifications

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

Responsibilities

• Oversee complex utilization and retrospective clinical reviews across multiple lines of business.
• Assess medical necessity, coding accuracy, treatment plans, discharge planning, and compliance requirements.
• Support clinical consistency, process improvement, quality, timeliness, and escalation of high-risk cases.

Education

Associate Degree in Nursing

Bachelor of Science in Nursing or advanced degree

Job description

Overview

Your Role

The Utilization Management team independently manages complex utilization and retrospective clinical reviews across multiple lines of business, assessing medical necessity, coding accuracy, treatment plans, discharge planning, and compliance requirements while supporting clinical consistency, process improvement, quality, timeliness, and appropriate escalation of high-risk cases.

Our leadership model is about developing great leaders at all levels and creating opportunities for our people to grow - personally, professionally, and financially. We are looking for leaders that are energized by creative and critical thinking, building and sustaining high-performing teams, getting results the right way, and fostering continuous learning.

Your Knowledge and Experience

• Associate Degree in Nursing required
• Bachelor of Science in Nursing or advanced degree is preferred
• 5 years of prior relevant experience in a managed care environment or clinical setting
• Maintain active, unrestricted RN License in assigned states or the ability to obtain required state (in addition to primary state license) RN license within 90 days of hire

Hybrid Virtual Work

This role allows employees to work virtually full-time, however employees will be expected to come to the office based on business need.