Lead Utilization Management Nurse Consultant

Your Role The Utilization Management team plays a crucial role in the accurate and timely management of prior authorizations and inpatient stay reviews for our members. As a Lead Utilization Management Nurse Consultant, you will help ensure that established guidelines for nationally recognized levels of care are correctly applied—including concurrent review, transplant, and NICU/HROB—for our Shared Services department. You will report directly to the Manager of Utilization and Medical Review. In this pivotal position, you will support the clinical team conducting first-level determination approvals for members by utilizing BSC evidence-based guidelines, policies, and industry-standard clinical criteria across various lines of business, including Commercial, Medi-Cal, and Medicare. The ideal candidate will leverage clinical judgment and extensive knowledge of benefit plans to thoroughly review authorization requests for medical necessity, coding accuracy, and policy compliance. Your contributions will extend to departmental operations, where you will engage in case reviews, audits, inquiry responses, training initiatives, and system testing. Our leadership model emphasizes the growth of exceptional leaders at all levels while fostering personal, professional, and financial development. We seek individuals who thrive on creative and critical thinking, building and sustaining high-performing teams, achieving results ethically, and encouraging a culture of continuous learning. Your Knowledge and Experience Bachelor of Science in Nursing or an Advanced Degree is preferred A valid California RN License is required A minimum of 7 years of relevant experience is necessary Practical knowledge in the field typically comes from advanced education and extensive experience The ability to collaborate effectively with cross-functional teams is essential Strong emotional intelligence skills are required Prior experience in transplant utilization management review is highly desirable

Created: 2026-03-04