Utilization Management Nurse, Senior- Medicare Concurrent Review

Utilization Management Nurse, Senior- Medicare Concurrent Review Blue Shield of CA United States, California, El Dorado Hills 4205 Town Center Boulevard (Show on map) Apr 23, 2026 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 Bachelor of Science in Nursing or advanced degree preferred.
Requires a current California RN License
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.