Utilization Management Nurse, Senior

Blue Shield of California•El Dorado Hills, CA

3h•$90,860 - $153,636•Hybrid

About The Position

The Utilization Management Nurse, Senior supports the Utilization Management team in completing accurate and timely prior authorization and inpatient stay reviews for members. The role supports clinicians performing first-level determinations using evidence-based guidelines, policies, and nationally recognized clinical criteria across lines of business, including Commercial, Medi-Cal, and Medicare. The nurse reviews authorization requests for medical necessity, coding accuracy, medical policy compliance, and contract compliance, applying clinical judgment and detailed knowledge of benefit plans. The role also supports department operations through case review, auditing, responding to inquiries, training, and system testing. It reports to the Manager, Utilization and Medical Review. Employees may work virtually full-time, with office attendance expected based on business need.

Requirements

Maintain an active, unrestricted California RN license.
Associate degree in nursing.
At least 5 years of prior relevant experience.
Strong communication and computer navigation skills.
Independent motivation and a strong work ethic.
Strong critical-thinking skills.

Nice To Haves

Bachelor of Science in Nursing.
Strong teamwork and collaboration skills.

Responsibilities

Perform prospective, concurrent, and retrospective utilization reviews and first-level determination approvals using evidence-based guidelines, policies, and nationally recognized clinical criteria.
Review cases for medical necessity, coding accuracy, medical policy compliance, and contract compliance.
Ensure discharge planning is appropriate to members’ needs and acuity, and determine post-acute needs, including levels of care, durable medical equipment, and post-service needs.
Develop and review member-centered documentation and correspondence that reflect determinations and comply with regulatory and accreditation standards.
Identify potential quality-of-care issues and service or treatment delays, and intervene as clinically appropriate.
Support consistent caseload and workload management to meet team goals, regulatory timelines, and accreditation standards.
Conduct scheduled system and letter testing.
Conduct department new-hire and supplemental training.
Perform monthly internal case auditing.
Triage and prioritize cases to meet required turnaround times and expedite access to appropriate care for members with urgent needs.
Maintain a HIPAA-compliant workspace in the telework environment.
Perform other duties as assigned.