Utilization Management Nurse, Senior

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

Job summary

Blue Shield of CA is seeking a Nursing Leader for Utilization Management to oversee complex clinical reviews across multiple lines of business, ensuring medical necessity, coding accuracy, and appropriate discharge planning. The role emphasizes clinical leadership, process improvement, and adherence to regulatory requirements.

In this hybrid virtual position, you will collaborate with cross-functional teams, drive quality and timeliness, and escalate high-risk cases as needed within a supportive

Qualifications

• Must have an Associate Degree in Nursing.
• BSN or higher preferred.
• 5 years of prior relevant experience in a 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

• 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.

Skills

Clinical assessment

Leadership in healthcare teams

Education

Associate Degree in Nursing

BSN or higher

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.