Utilization Management Nurse, Senior
Company: Blue Shield of California
Location: Rancho Cordova
Posted on: June 29, 2025
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Job Description:
Your Role The Utilization Management team reviews the inpatient
stays for our members and correctly applies the guidelines for
nationally recognized levels of care. The Utilization Management
Nurse will report to the Utilization Management Nurse Manager. In
this role you will be assigned a list of inpatient facilities and
then review clinical information provided by the facilities to
determine medical necessity when our members admit. You will also
be involved with discharge planning and transfers as needed for
higher levels of care or out of network admissions. Your Work In
this role, you will: Perform prospective, concurrent and
retrospective utilization reviews and first level determination
approvals for members using BSC evidenced based guidelines,
policies and nationally recognized clinal criteria across lines of
business or for a specific line of business such as Medicare and
FEP Conducts clinical review of claims for medical necessity,
coding accuracy, medical policy compliance and contract compliance
Ensure discharge (DC) planning at levels of care appropriate for
the members needs and acuity and determine post-acute needs of
member including levels of care, durable medical equipment, and
post service needs to ensure quality and cost-appropriate DC
planning Prepare and present cases to Medical Director (MD) for
medical director oversight and necessity determination and
communicate determinations to providers and/or members to in
compliance with state, federal and accreditation requirements
Develop and review member centered documentation and correspondence
reflecting determinations in compliance with regulatory and
accreditation standards and identify potential quality of care
issues, service or treatment delays and intervenes or as clinically
appropriate Refer to Case Management when there are acute inpatient
needs affecting discharge Attend staff meetings, clinical rounds
and weekly huddles Maintain quality and productivity metrics for
all casework Buddy or support new employees Maintaining HIPAA
compliant workspace for telework environment Your Knowledge and
Experience Bachelors 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
Keywords: Blue Shield of California, San Bruno , Utilization Management Nurse, Senior, Healthcare , Rancho Cordova, California
