Verified Job
Healthcare
Blue Shield of California Utilization Management Nurse, Senior
Healthcare
#804515
Remote / WFH
Blue Shield of California
Job Description
Job highlights
Identified by Google from the original job post
Qualifications
Associate Degree in Nursing required
5 years of prior relevant experience managed care environment or clinical setting
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
Human
We strive to listen and communicate effectively, showing empathy by understanding others' perspectives
Courageous
The Company reserves the right to require more presence in the office based on business needs, and requirements are subject to change with periodic reviews
External hires must pass a background check/drug screen
Qualified applicants with arrest records and/or conviction records will be considered for employment in a manner consistent with Federal, State and local laws, including but not limited to the San Francisco Fair Chance Ordinance
Benefits
Pay Range for California : $90860.00 to $136290.00
Pay Range for Bay Area : $102424.00 to $153636.00
Note : Please note that this range represents the pay range for this and many other positions at Blue Shield that fall into this pay grade
Blue Shield salaries are based on a variety of factors, including the candidate experience, location (California, Bay Area, or outside California), and current employee salaries for similar roles
Responsibilities
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
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
This role allows employees to work virtually full-time, however employees will be expected to come to the office based on business need
For most teams, this means coming into the office two days per week
Employees living more than 50 miles from an office location, out of state employees, and employees in certain member-facing roles should work with their manager to determine in-office time based on business need
Office Environment - roles involving part to full time schedule in Office Environment
Based in our physical offices and work from home office/deskwork - Activity level: Sedentary, frequency most of work day
Job description
Job Description
Your Role
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.
Responsibilities
Your Work
In this role, you will:
• 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
Qualifications
Your Knowledge and Experience
• Associate Degree in Nursing required
• Bachelor of Science in Nursing or advanced degree is preferred
• 5 years of prior relevant experience managed care environment or clinical setting
• 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
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.
About Us
About Blue Shield of California
As of January 2025, Blue Shield of California became a subsidiary of Ascendiun. Ascendiun is a nonprofit corporate entity that is the parent to a family of organizations including Blue Shield of California and its subsidiary, Blue Shield of California Promise Health Plan; Altais, a clinical services company; and Stellarus, a company designed to scale healthcare solutions. Together, these organizations are referred to as the Ascendiun Family of Companies.
At Blue Shield of California, our mission is to create a healthcare system worthy of our family and friends and sustainably affordable. We are transforming health care in a way that genuinely serves our nonprofit mission by lowering costs, improving quality, and enhancing the member and physician experience.
To achieve our mission, we foster an environment where all employees can thrive and contribute fully to address the needs of the various communities we serve. We are committed to creating and maintaining a supportive workplace that upholds our values and advances our goals.
Blue Shield is a U.S. News Best Company to work for, a Deloitte U.S. Best Managed Company and a Top 100 Inspiring Workplace. We were recognized by Fair360 as a Top Regional Company, and one of the 50 most community-minded companies in the United States by Points of Light. Here at Blue Shield, we strive to make a positive change across our industry and communities – join us!
Our Values:
• Honest. We hold ourselves to the highest ethical and integrity standards. We build trust by doing what we say we're going to do and by acknowledging and correcting where we fall short.
• Human. We strive to listen and communicate effectively, showing empathy by understanding others' perspectives.
• Courageous. We stand up for what we believe in and are committed to the hard work necessary to achieve our ambitious goals.
Our Workplace Model
We believe in fostering a workplace environment that balances purposeful in-person collaboration with flexibility - providing clear expectations while respecting the diverse needs of our workforce. Our workplace model is designed around intentional in-person interaction, collaboration, connection, creativity and flexibility:
• For most teams, this means coming into the office two days per week.
• Employees living more than 50 miles from an office location, out of state employees, and employees in certain member-facing roles should work with their manager to determine in-office time based on business need.
• For employees with medical conditions that may impact their ability to work in-office, we are committed to engaging in an interactive process and providing reasonable accommodations to ensure their work environment is conducive to their success and well-being.
The Company reserves the right to require more presence in the office based on business needs, and requirements are subject to change with periodic reviews.
Physical Requirements:
Office Environment - roles involving part to full time schedule in Office Environment. Based in our physical offices and work from home office/deskwork - Activity level: Sedentary, frequency most of work day.
Please click here for further physical requirement detail.
Equal Employment Opportunity:
External hires must pass a background check/drug screen. Qualified applicants with arrest records and/or conviction records will be considered for employment in a manner consistent with Federal, State and local laws, including but not limited to the San Francisco Fair Chance Ordinance. All qualified applicants will receive consideration for employment without regards to race, color, religion, sex, national origin, ****** orientation, gender identity, protected veteran status or disability status and any other classification protected by Federal, State and local laws.
JOB INFO
Job Identification : 20261259
Job Category : Healthcare Services and Operations
Posting Date : 2026-07-06T22:15:39+00:00
Job Schedule : Full time
Locations :
El Dorado Hills, CA, United States
CA, United States
Long Beach, CA, United States
Lodi, CA, United States
Oakland, CA, United States
Rancho Cordova, CA, United States
Redding, CA, United States
San Diego, CA, United States
Woodland Hills, CA, United States
Pay Range for California : $90860.00 to $136290.00
Pay Range for Bay Area : $102424.00 to $153636.00
Note : Please note that this range represents the pay range for this and many other positions at Blue Shield that fall into this pay grade. Blue Shield salaries are based on a variety of factors, including the candidate experience, location (California, Bay Area, or outside California), and current employee salaries for similar roles.
Role can be filled by a candidate requiring sponsorship : No
Identified by Google from the original job post
Qualifications
Associate Degree in Nursing required
5 years of prior relevant experience managed care environment or clinical setting
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
Human
We strive to listen and communicate effectively, showing empathy by understanding others' perspectives
Courageous
The Company reserves the right to require more presence in the office based on business needs, and requirements are subject to change with periodic reviews
External hires must pass a background check/drug screen
Qualified applicants with arrest records and/or conviction records will be considered for employment in a manner consistent with Federal, State and local laws, including but not limited to the San Francisco Fair Chance Ordinance
Benefits
Pay Range for California : $90860.00 to $136290.00
Pay Range for Bay Area : $102424.00 to $153636.00
Note : Please note that this range represents the pay range for this and many other positions at Blue Shield that fall into this pay grade
Blue Shield salaries are based on a variety of factors, including the candidate experience, location (California, Bay Area, or outside California), and current employee salaries for similar roles
Responsibilities
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
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
This role allows employees to work virtually full-time, however employees will be expected to come to the office based on business need
For most teams, this means coming into the office two days per week
Employees living more than 50 miles from an office location, out of state employees, and employees in certain member-facing roles should work with their manager to determine in-office time based on business need
Office Environment - roles involving part to full time schedule in Office Environment
Based in our physical offices and work from home office/deskwork - Activity level: Sedentary, frequency most of work day
Job description
Job Description
Your Role
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.
Responsibilities
Your Work
In this role, you will:
• 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
Qualifications
Your Knowledge and Experience
• Associate Degree in Nursing required
• Bachelor of Science in Nursing or advanced degree is preferred
• 5 years of prior relevant experience managed care environment or clinical setting
• 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
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.
About Us
About Blue Shield of California
As of January 2025, Blue Shield of California became a subsidiary of Ascendiun. Ascendiun is a nonprofit corporate entity that is the parent to a family of organizations including Blue Shield of California and its subsidiary, Blue Shield of California Promise Health Plan; Altais, a clinical services company; and Stellarus, a company designed to scale healthcare solutions. Together, these organizations are referred to as the Ascendiun Family of Companies.
At Blue Shield of California, our mission is to create a healthcare system worthy of our family and friends and sustainably affordable. We are transforming health care in a way that genuinely serves our nonprofit mission by lowering costs, improving quality, and enhancing the member and physician experience.
To achieve our mission, we foster an environment where all employees can thrive and contribute fully to address the needs of the various communities we serve. We are committed to creating and maintaining a supportive workplace that upholds our values and advances our goals.
Blue Shield is a U.S. News Best Company to work for, a Deloitte U.S. Best Managed Company and a Top 100 Inspiring Workplace. We were recognized by Fair360 as a Top Regional Company, and one of the 50 most community-minded companies in the United States by Points of Light. Here at Blue Shield, we strive to make a positive change across our industry and communities – join us!
Our Values:
• Honest. We hold ourselves to the highest ethical and integrity standards. We build trust by doing what we say we're going to do and by acknowledging and correcting where we fall short.
• Human. We strive to listen and communicate effectively, showing empathy by understanding others' perspectives.
• Courageous. We stand up for what we believe in and are committed to the hard work necessary to achieve our ambitious goals.
Our Workplace Model
We believe in fostering a workplace environment that balances purposeful in-person collaboration with flexibility - providing clear expectations while respecting the diverse needs of our workforce. Our workplace model is designed around intentional in-person interaction, collaboration, connection, creativity and flexibility:
• For most teams, this means coming into the office two days per week.
• Employees living more than 50 miles from an office location, out of state employees, and employees in certain member-facing roles should work with their manager to determine in-office time based on business need.
• For employees with medical conditions that may impact their ability to work in-office, we are committed to engaging in an interactive process and providing reasonable accommodations to ensure their work environment is conducive to their success and well-being.
The Company reserves the right to require more presence in the office based on business needs, and requirements are subject to change with periodic reviews.
Physical Requirements:
Office Environment - roles involving part to full time schedule in Office Environment. Based in our physical offices and work from home office/deskwork - Activity level: Sedentary, frequency most of work day.
Please click here for further physical requirement detail.
Equal Employment Opportunity:
External hires must pass a background check/drug screen. Qualified applicants with arrest records and/or conviction records will be considered for employment in a manner consistent with Federal, State and local laws, including but not limited to the San Francisco Fair Chance Ordinance. All qualified applicants will receive consideration for employment without regards to race, color, religion, sex, national origin, ****** orientation, gender identity, protected veteran status or disability status and any other classification protected by Federal, State and local laws.
JOB INFO
Job Identification : 20261259
Job Category : Healthcare Services and Operations
Posting Date : 2026-07-06T22:15:39+00:00
Job Schedule : Full time
Locations :
El Dorado Hills, CA, United States
CA, United States
Long Beach, CA, United States
Lodi, CA, United States
Oakland, CA, United States
Rancho Cordova, CA, United States
Redding, CA, United States
San Diego, CA, United States
Woodland Hills, CA, United States
Pay Range for California : $90860.00 to $136290.00
Pay Range for Bay Area : $102424.00 to $153636.00
Note : Please note that this range represents the pay range for this and many other positions at Blue Shield that fall into this pay grade. Blue Shield salaries are based on a variety of factors, including the candidate experience, location (California, Bay Area, or outside California), and current employee salaries for similar roles.
Role can be filled by a candidate requiring sponsorship : No
