Utilization Management Nurse, Senior

Blue Shield of California • El Dorado, AR

3d • Hybrid

About The Position

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.

Requirements

• Associate Degree in Nursing required
• 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

Nice To Haves

• Bachelor of Science in Nursing or advanced degree is preferred
• 5 years of prior relevant experience managed care environment or clinical setting

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

What This Job Offers

• Job Type: Full-time
• Career Level: Senior
• Education Level: Associate degree