Medical Policy Utilization Management Nurse

1 week ago


Rancho Cordova, California, United States Blue Shield of California Full time
Job Summary

As a Medical Policy Utilization Management Nurse, you will play a critical role in ensuring the quality and cost-effectiveness of healthcare services for our members. You will be responsible for conducting clinical reviews of claims to determine medical necessity, coding accuracy, and compliance with medical policies and contracts.

Key Responsibilities:

  • Conduct prospective, concurrent, and retrospective utilization reviews to determine medical necessity and approve or deny claims
  • Review clinical information provided by facilities to determine medical necessity and make recommendations for discharge planning
  • Collaborate with the Utilization Management Nurse Manager to develop and implement utilization management strategies
  • Prepare and present cases to the Medical Director for review and approval
  • Develop and maintain accurate and comprehensive documentation of all utilization management activities

Requirements:

  • Bachelor's degree in Nursing or equivalent experience
  • Strong communication and computer navigation skills
  • Ability to work independently and as part of a team
  • Excellent analytical and problem-solving skills

What We Offer:

  • A competitive salary and benefits package
  • Opportunities for professional growth and development
  • A dynamic and supportive work environment


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