POSITION SUMMARY
We are seeking a Registered Nurse (RN) with Utilization Management experience to review medical service requests using nationally recognized clinical guidelines, ensuring appropriate, high-quality, and cost-effective care for health plan members. This remote role may focus on Prior Authorization, Concurrent Review, Discharge Planning, or Grievance & Appeals while collaborating with interdisciplinary teams to support care coordination and member outcomes.
Requirements:
- Bachelor's Degree (four-year college or technical school) preferred, Field of Study: Nursing, Healthcare, Case Management
- Utilization Review experience
- Medicare, Medi-Cal and related policy and regulations knowledge
- RN, California Board Certified Registered Nurse License required
Responsibilities:
- Under the direction of the Manager, Utilization Management (UM), the RN, Utilization Management Nurse, will review requests for medical services against National Clinical Guidelines.
- The RN, Utilization Management Nurse, uses judgment in selecting appropriate guidelines and in applying general policies and procedures.
- Responsible for assuring the receipt of high quality, cost-efficient medical outcomes for those enrollees identified as having the need for inpatient and/or outpatient authorization and discharge planning for post-acute settings.
- Responsible for screening enrollees for initiatives and programs including Case Management, Enhanced Care Management and California Children’s Services (CCS).
- The RN, Utilization Management Nurse will be assigned to one of the following functional areas: Prior Authorization, Concurrent Stay Review, Discharge Planning or Grievance and Appeals.
#INDCC
Pay: From $55.00 per hour
Benefits:
- 401(k)
- Dental insurance
- Health insurance
- Vision insurance
Experience:
- Utilization management: 2 years (Required)
- Medi-Cal: 1 year (Required)
License/Certification:
- California RN License (Required)
Work Location: Remote
