Top 9102 Nurse utilization management 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
Registered Nurse Utilization Review, Case Management, Part Time,7P-7:30A
Baptist Health South Florida —South Miami, FL
- $73,860.80 - $98,234.86 a year
- Part-time
- Nursing
- RN License
- Mid-level
- Wellness program
- Health insurance
3d
Utilization Management Nurse
Applied Underwriters —Omaha, NE
- Full-time
- Nursing
- Microsoft Excel
- Microsoft Outlook
- Paid training
- Paid holidays
Quick Apply
Utilization Management Nurse
TEXAS INDEPENDENCE HEALTH PLAN INC —Austin, TX
- Weekends as needed
- Hybrid work
- Nursing
- Microsoft Excel
- Microsoft Outlook
Quick Apply
Nurse Case Manager, Utilization Management
1199SEIU Family of Funds —New York, NY
- $89,400 - $106,100 a year
- Full-time
- Nursing
- RN License
- Mid-level
ISNP Utilization Management Nurse
Longevity Health —Remote
- Full-time
- Nursing
- Clean driving record
- RN License
Quick Apply
9d
Health Nurse - Utilization Management
Alterwood Health —Remote
- $75,000 - $95,000 a year
- Full-time
- Microsoft Word
- Background check
- Nursing
- Health savings account
- Disability insurance
Quick Apply
11d
Utilization Management Nurse
Blue Eagle Consulting —Remote
- RN License
- Mid-level
- Nursing
Quick Apply
Utilization Management Nurse Consultant
CVS Health —Pennsylvania
- $29.10 - $62.32 an hour
- Weekends as needed
- Remote
- Nursing
- RN License
- Mid-level
- Health insurance
- Dental insurance
Utilization Management Registered Nurse
West Coast Consulting —Remote
- $30 - $34 an hour
- Contract
- Remote
- RN License
- Mid-level
- Nursing
- 401(k)
Quick Apply
9d
Utilization Review Nurse
Nora Concierge Care —Syracuse, NY
- $65 an hour
- Contract
- RN License
- BLS Certification
- HIPAA
Quick Apply
9d
Clinical Guide Part A: Utilization Management Nurse
Devoted Health —Remote
- $85,000 - $95,000 a year
- Full-time
- Remote
- RN License
- Mid-level
- 3 years
- Dental insurance
- 401(k)
9d
Utilization Review Nurse
Health Business Solutions LLC —Remote
- Remote
- Nursing
- RN License
- Bachelor of Science
11d
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
Medical Management - Medical Review Examiner Nurse 135-1009
CommunityCare —Remote
- Full-time
- Remote
- Background check
- Nursing
- RN License
Quick Apply
9d
Clinical Review Nurse
TurningPoint Healthcare Solutions, LLC —Remote
- $52,000 - $68,000 a year
- Remote
- Nursing
- RN License
- Computer literacy
Quick Apply
Utilization Management Nurse Lead
Humana —Michigan
- $94,900 - $130,500 a year
- Full-time
- Remote
- Nursing
- RN License
- Master's degree
- Paid parental leave
- Paid holidays
9d
Medical Management - Utilization Management RN 145-2011
CommunityCare —Remote
- Full-time
- Remote
- Background check
- Nursing
- RN License
Quick Apply
9d
Denials & Appeals Administrator (RN)
Boston Medical Center —Remote
- $43.03 - $62.50 an hour
- Full-time
- Remote
- Nursing
- RN License
- 5 years
- Health insurance
- Dental insurance
CA Utilization Review Nurse I
CorVel Corporation —Rancho Cucamonga, CA
- $30.64 - $45.80 an hour
- Full-time
- Remote
- Nursing
- LVN
- RN License
- Health savings account
- Disability insurance
Quick Apply

I want to receive the latest job alert for nurse utilization management

By signing in to your account, you agree to SimplyHired's Terms of Service and consent to our Cookie and Privacy Policy.

Explore jobs in more locations

nurse utilization management jobs near

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

Refine Your Search

nurse utilization management jobs

Utilization Management Outpatient Authorization Nurse

Registered Nurse Utilization Review, Case Management, Part Time,7P-7:30A

Utilization Management Nurse

Utilization Management Nurse

Nurse Case Manager, Utilization Management

ISNP Utilization Management Nurse

Health Nurse - Utilization Management

Utilization Management Nurse

Utilization Management Nurse Consultant

Utilization Management Registered Nurse

Utilization Review Nurse

Clinical Guide Part A: Utilization Management Nurse

Utilization Review Nurse

Utilization Review Nurse

Medical Management - Medical Review Examiner Nurse 135-1009

Clinical Review Nurse

Utilization Management Nurse Lead

Medical Management - Utilization Management RN 145-2011

Denials & Appeals Administrator (RN)

CA Utilization Review Nurse I

I want to receive the latest job alert for nurse utilization management

Related Searches

Explore jobs in more locations

Job Seeker Tools

Employer Tools

Browse

Stay Connected