Top 183 Milliman care Jobs

Utilization Management Outpatient Authorization Nurse
Champion Health Plan is a Medicare Advantage Prescription Drug HMO C-SNP serving Medicare beneficiaries with End-Stage Renal Disease. —Long Beach, CA
- From $67,000 a year
- Full-time
- Nursing
- LVN
- HIPAA
- Health insurance
- Dental insurance
Quick Apply
Utilization Review Nurse
University Medical Center of Southern Nevada —Las Vegas, NV
- $40.72 - $63.12 an hour
- Weekends as needed
- Nursing
- RN License
- Office
- Health insurance
- Dental insurance
Quick Apply
Licensed Practical Nurse Referral Reviewer
Zimmerman Associates, Inc. —Bethesda, MD
- $34.57 an hour
- Nursing
- Microsoft Excel
- Microsoft Outlook
Utilization Management and Discharge Planning RN
Santa Clara Family Health Plan —San Jose, CA
- $100,968 - $151,451 a year
- Temporary
- Hybrid work
- Nursing
- Skilled nursing facility
- RN License
- Wellness program
- Health insurance
Quick Apply
4d
Director - Care Management
Piedmont Healthcare —Augusta, GA
- Full-time
- RN License
- Hospital
- Licensed Clinical Social Worker
Director - Care Management
Piedmont Healthcare —Stockbridge, GA
- Full-time
- Nursing
- RN License
- Hospital
Referral Management (Non-Nurse) Reviewer
Zimmerman Associates, Inc. —Bethesda, MD
- $24.13 an hour
- Microsoft Excel
- Microsoft Outlook
- Mid-level
Referral Management (Non-Nurse) Reviewer
Zimmerman Associates, Inc. —Bethesda, MD
- $23.56 an hour
- Microsoft Excel
- Microsoft Outlook
- Mid-level
RN Case Manager - Per Diem
Jupiter Medical Center —Jupiter, FL
- Per diem
- Nursing
- RN License
- Hospital
Senior Manager, Utilization Management
1199SEIU Family of Funds —New York, NY
- $125,400 - $156,700 a year
- Full-time
- Nursing
- 6 years
- RN License
Registered Nurse Care Manager - Pediatric Rheumatology
Christus Health —San Antonio, TX
- 8 hour shift
- Spanish
- CPR Certification
- Nursing
3d
Clinical Access Case Manager (RN)
Career Land Center, LLC —Farmington, NM
- Full-time
- Nursing
- RN License
- BLS Certification
- Paid holidays
- Health insurance
Quick Apply
Utilization Management Nurse
TEXAS INDEPENDENCE HEALTH PLAN INC —Austin, TX
- Weekends as needed
- Hybrid work
- Nursing
- Microsoft Excel
- Microsoft Outlook
Quick Apply
System Director, Authorization Management & Pre-Service
Norton Healthcare —Louisville, KY
- Full-time
- Background check
- Nursing
- RN License
- Paid parental leave
- Paid holidays
Travel Registered Nurse - Case Management/Utilization Review
Quality Staffing Specialists —Kinston, NC
- $2,520 a week
- Full-time
- Acute care
- Background check
- RN License
- Continuing education credits
- Disability insurance
Quick Apply
6d
RN Case Manager - Full Time
Jupiter Medical Center —Jupiter, FL
- Full-time
- Nursing
- RN License
- Hospital
12d
Utilization Review Nurse
Cobalt Benefits Group LLC —Dallas, TX
- $90,000 - $98,000 a year
- Full-time
- Remote
- Nursing
- Microsoft Excel
- Microsoft Outlook
- Health savings account
- AD&D insurance
Quick Apply
Holistic Health Specialist - Work From Home
Health Care Service Corporation —Chicago, IL
- $61,500 - $136,100 a year
- Full-time
- Remote
- Nursing
- Management
- RN License
- Work from home
LVN- Case Manager - Ambulatory Care - Hybrid
Cedars-Sinai —Beverly Hills, CA
- $47.35 - $75.76 an hour
- 8 hour shift
- LVN
- Hospital
- Mid-level
- Dental insurance
- 403(b)
Care Manager (RN) **Hospital Care Management Experience Highly Preferred** (Sunday-Thursday, 8:00AM-4:00PM)
NYU Langone Health —Mineola, NY
- $147,153.96 - $180,190.08 a year
- Nursing
- RN License
- Computer literacy
- Wellness program

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Utilization Management Outpatient Authorization Nurse

Champion Health Plan is a Medicare Advantage Prescription Drug HMO C-SNP serving Medicare beneficiaries with End-Stage Renal Disease.
Long Beach, CA

Quick Apply

Job Details

Full-time
From $67,000 a year

Benefits

Health insurance
Dental insurance
401(k)
Vision insurance
Life insurance

Qualifications

Nursing
LVN
Outpatient experience
Bachelor's degree
Utilization management
Attention to detail
Organizational skills
Nursing
Time management

Full Job Description

Job Overview

The Utilization Management Pre-Authorization Nurse is responsible for managing outpatient utilization by conducting thorough reviews of clinical documentation and applying clinical knowledge in accordance with Milliman Care Guidelines (MCG), InterQual Criteria, Medicare Advantage (MCAL), and CMS regulations. This role ensures that all authorizations, deferrals, and denials are processed efficiently, accurately, and in compliance with company policies and regulatory standards, including CMS, Department of Health Care Services (DHCS), and Department of Managed Health Care (DMHC) requirements. The nurse also issues timely and accurate denial, deferral, or authorization letters, manages clinical review processes, and supports compliance with health plan guidelines.

KEY RESPONSIBILITIES

Manage all authorizations, deferrals, and denials by conducting comprehensive reviews of clinical documentation, applying clinical criteria and guidelines such as MCG, InterQual, UpToDate, and CMS.
Review authorizations, deferrals, and denials for medical necessity, ensuring adherence to regulatory and health plan criteria, policies, and Evidence of Coverage (EOC).
Apply clinical knowledge when processing deferrals and denials, supported by regulatory guidelines from CMS, DMHC, DHCS, and health plan policies.
Ensure timely and accurate processing of all authorizations, deferrals, and denials in compliance with company and departmental policies and procedures.
Process 30-40 deferral or denial letters daily with accuracy, maintaining high standards of quality.
Review and process denials, modifications, and carve-outs according to established procedures and clinical criteria.
Use clinical expertise to apply MCG, InterQual, and other relevant clinical guidelines to ensure that medical decisions align with best practices and regulations.
Review all applicable benefit policies and Evidence of Coverage (EOC) to ensure accurate decisions regarding coverage and medical necessity.
Collaborate with healthcare providers, the Utilization Management (UM) team, and compliance departments to ensure clear communication and appropriate utilization of healthcare services.
Coordinate with the Appeals team to support the completion of appeal and denial letters as needed.
Comply with internal policies and procedures to ensure timely and accurate processing of all deferrals, denials, and modification requests.
Stay up-to-date with changes in regulatory requirements (CMS, DMHC, DHCS) and integrate new policies into daily processes.
Perform additional duties, projects, and actions as assigned to support department goals and operational needs.

QUALIFICATIONSEducation

Licensed Vocational Nurse (LVN) with an active, unrestricted license in the state of practice.
Bachelor’s degree in Nursing (preferred, but not required).

Experience

Minimum of 3 years of clinical nursing experience, with a focus on Utilization Management or managed care preferred.
Familiarity with Milliman Care Guidelines (MCG), InterQual, Medicare, Medicaid, and CMS regulations.
Utilization management experience with a Health Plan or Management Services Organization (MSO).

Knowledge, Skills, and Abilities

Strong knowledge of MCG, InterQual Criteria, Medicare (MCAL), and CMS guidelines.
Proficient in applying clinical knowledge to support medical necessity decisions based on health plan policies, benefit guidelines, and regulatory criteria.
Excellent organizational skills and the ability to process a high volume of deferral and denial letters with accuracy and attention to detail.
Strong communication skills, both verbal and written, especially in creating clear and compliant deferral and denial letters.
Ability to collaborate with cross-functional teams, including providers and internal UM teams.
Exceptional follow-through abilities to track all outstanding tasks and coordinate with assigned owners to ensure tasks are completed in a timely manner.
Strong organizational skills, attention to detail, and sound decision-making skills required.
Ability to manage multiple projects of varying complexity, priority levels, and deadlines.
Proficient knowledge of Health Plan, DMHC, DHCS, CMS, HIPAA, and NCQA requirements.

PROFESSIONAL COMPETENCIES

Strong problem-solving skills with the ability to analyze and apply clinical guidelines and policies.
Excellent organizational and time management skills to meet deadlines while maintaining accuracy.
Ability to thrive in a fast-paced, results-driven environment.

WORK ENVIRONMENT AND PHYSICAL REQUIREMENTS

The majority of work responsibilities are performed in an office setting, working on a computer.
Regularly required to talk, hear, stand, walk, sit, and use hands to handle or feel objects and controls.

Job Type: Full-time

Pay: From $67,000.00 per year

Benefits:

401(k)
Dental insurance
Health insurance
Life insurance
Vision insurance

Experience:

Outpatient: 3 years (Required)
Utilization management: 3 years (Preferred)

License/Certification:

LVN (Preferred)

Location:

Long Beach, CA 90815 (Required)

Work Location: In person

Quick Apply

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