Top 8647 Utilization management nurse 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
Care Review Clinician (RN) - Remote in FL
Molina Healthcare, Inc. —Miami, FL
- $26.41 - $51.49 an hour
- Full-time
- Remote
- RN License
- Mid-level
- Critical & Intensive Care
- Health insurance
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
Care Review Clinician (RN) - Remote in FL
Molina Healthcare, Inc. —Tampa, FL
- $26.41 - $51.49 an hour
- Full-time
- Remote
- RN License
- Mid-level
- Critical & Intensive Care
- Health insurance
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
ISNP Utilization Management Nurse
Longevity Health —Remote
- Full-time
- Nursing
- Clean driving record
- RN License
Quick Apply
9d
Concurrent Utilization Review Nurse, RN
NeueHealth —Los Angeles, CA
- $74,286.15 - $111,429.23 a year
- Remote
- Nursing
- RN License
- Mid-level
- Paid holidays
- Health insurance
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
10d
Utilization Management Nurse
Brighton Health Plan Solutions, LLC —Remote
- Full-time
- Nursing
- Microsoft Excel
- Microsoft Outlook
Quick Apply
12d
Utilization Review Nurse- Remote
Gainwell Technologies —Alaska
- $78,000 - $88,000 a year
- Extended hours
- Remote
- Background check
- RN License
- Mid-level
- Health insurance
- Tuition reimbursement
Utilization Management Nurse (contract)
Elevance Health —Atlanta, GA
- Contract
- Hybrid work
- 6 years
- LVN
- RN License
- Health savings account
- Disability insurance
9d
Medical Management - Utilization Management RN 145-2026
CommunityCare —Remote
- Full-time
- Remote
- Background check
- Nursing
- RN License
Quick Apply
9d
Utilization Management Registered Nurse
West Coast Consulting —Remote
- $30 - $34 an hour
- Contract
- Remote
- RN License
- Mid-level
- Nursing
- 401(k)
Quick Apply
9d
Registered Nurse / RN - Utilization Management I
CareOregon —Portland, OR
- $102,330 - $125,070 a year
- Full-time
- RN License
- Customer service
- Computer literacy
- Wellness program
- Paid jury duty
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
Registered Nurse Utilization Review, Case Management
South Miami Hospital —Florida
- $73,860.80 - $98,234.86 a year
- Nursing
- RN License
- Mid-level
- Wellness program
- Health insurance
Case Manager, Registered Nurse (Oncology experience required)
CVS Health —Oregon
- $54,095 - $155,538 a year
- Full-time
- Remote
- Spanish
- Nursing
- RN License
- Health insurance
- Dental insurance
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
Utilization Management Nurse Specialist RN II
L.A. Care Health Plan —Los Angeles, CA
- $88,854 - $142,166 a year
- Weekends as needed
- Nursing
- Microsoft Outlook
- RN License
- Wellness program
- Health insurance
10d

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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

Refine Your Search

utilization management nurse jobs

Utilization Management Outpatient Authorization Nurse

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

Care Review Clinician (RN) - Remote in FL

Health Nurse - Utilization Management

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ISNP Utilization Management Nurse

Concurrent Utilization Review Nurse, RN

Utilization Management Nurse Lead

Utilization Management Nurse

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Utilization Management Nurse (contract)

Medical Management - Utilization Management RN 145-2026

Utilization Management Registered Nurse

Registered Nurse / RN - Utilization Management I

Utilization Management Nurse Consultant

Registered Nurse Utilization Review, Case Management

Case Manager, Registered Nurse (Oncology experience required)

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Utilization Management Nurse Specialist RN II

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