Utilization Management Nurse, Senior (Medicare Concurrent Review)

Blue Shield of CA; Springfield Meadows (CA); Hybrid; USD 90,000 - 115,000; Full time

Job summary

Blue Shield of CA is seeking an Utilization Management Concurrent Review Nurse to perform first-level determinations for authorization requests. You will apply evidence-based guidelines and national criteria across Medicare, Medical and Commercial plans, supporting medical necessity decisions with clinical judgment.

You must have a CA RN license and a nursing degree; 5+ years of experience and strong communication, teamwork, and critical thinking are essential.

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

• Perform first-level determination for authorization requests using evidence-based guidelines.
• Review for medical necessity and clinical judgment across Medicare, Medical, or Commercial plans.
• Collaborate with Utilization Management team and report to the Nurse Manager.
• Maintain knowledge of benefit plans and relevant policies.

Skills

Communication skills

Computer navigation

Teamwork

Independent motivation

Critical thinking

Education

Associate's degree in nursing

Bachelor of Science in Nursing

Job description

Your Role

The Utilization Management Concurrent Review team reviews the inpatient stays for our members and correctly applies guidelines for nationally recognized levels of care. The Utilization Management Concurrent Review Nurse will report to the Utilization Management Nurse Manager. In this role you will perform first level determination for authorization requests received for members using BSC evidence-based guidelines, policies, and nationally recognized criteria across specific lines of business such as Medicare, Medical, or Commercial plans. You will conduct reviews for authorization requests based on medical necessity and clinical judgment. Detailed knowledge of the benefit plans is necessary to complete review decisions.

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

• 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

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.