Utilization Management Nurse, Senior

February 28, 2026

Job Description Your Role The Federal Employee Program (FEP) team is committed to providing quality healthcare coverage to federal employees, retirees, and their families. The FEP Prior Authorization Review Utilization Management Nurse will report to the FEP Utilization Management Manager. In this role you will be part of a dynamic team responsible for prior authorization clinical reviews for services and medications for both inpatient and outpatient settings. You will ensure members receive services at the right level of care at the right time, in the right setting, while ensuring services are appropriate, medically necessary, and within their benefit in full collaboration with FEP Care Management. Ultimately contributing to decreasing the cost of healthcare. 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: <ul><li>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 </li><li>Conducts clinical review of prior authorization requests for medical necessity, coding accuracy, medical policy compliance and contract compliance. </li><li>Ensure discharge(DC) planning at levels of care appropriate for the members needs and </li><li>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 </li><li>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 </li><li>Provides referrals to Case Management, Disease Management, Appeals and Grievance and Quality Departments as necessary. Identifies potential Third-Party Liability and Coordination of Benefit cases and notifies appropriate internal departments. </li><li>Actively participates in staff meetings and huddles </li><li>Provides input into desk level procedures. </li></ul>Qualifications Your Knowledge and Experience <ul><li>Requires a bachelor's degree or equivalent experience</li><li>Requires a current California RN License </li><li>Requires at least 5 years of prior relevant experience</li><li>Previous experience in utilization management preferred</li><li>Strong computer skills related to Windows-based programs and applications</li><li>Varied acute care clinical background</li><li>Must be able to sit for extended periods of time and read clinical information on one computer screen and apply that information based on criteria or policy on a second computer screen to document the decision </li></ul>Hybrid Virtual Work This role allows employees to work virtually full-time, however employees will be expected to come into the office based on business need. About The Team 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: <ul><li>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. </li><li>Human. We strive to listen and communicate effectively, showing empathy by understanding others' perspectives. </li><li>Courageous. We stand up for what we believe in and are committed to the hard work necessary to achieve our ambitious goals. </li></ul>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: <ul><li>For most teams, this means coming into the office two days per week. </li><li>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. </li><li>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. </li></ul>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, sexual orientation, gender identity, protected veteran status or disability status and any other classification protected by Federal, State and local laws.

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