Top 665 Utilization management Jobs in Los Angeles Ca

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
Workers Comp Case Manager
Downtown LA Law Group —Los Angeles, CA
- $27.83 - $35.00 an hour
- Full-time
- Vital signs
- HIPAA
- Mid-level
- Health insurance
- 401(k)
Quick Apply
14d
RN, Care Manager Full-time, Day shift
Adventist Health —Glendale, CA
- $57.50 - $78.87 an hour
- Full-time
- Acute care
- Nursing
- Addiction Medicine
8d
RN, Care Manager
Adventist Health —Los Angeles, CA
- $57.50 - $78.87 an hour
- Full-time
- Acute care
- Nursing
- Addiction Medicine
LVN - Utilization Management
Cross Country Local —Montebello, CA
- $35 - $46 an hour
- 8 hour shift
- LVN
- BLS Certification
- Mid-level
- Health insurance
- 401(k) matching
Quick Apply
9d
Utilization Management Supervisor, Non-Clinical
UCLA Health —Los Angeles, CA
- $70,900 - $145,200 a year
- Writing skills
- Mid-level
- 3 years
Revenue Reimbursement Coordinator (Glendale) Full-time, Day
Adventist Health —Glendale, CA
- $39.16 - $53.71 an hour
- Full-time
- Medical office experience
- Mid-level
- Office
Licensed Practical Nurse - LPN -Utilization Management
Cross Country Local —Montebello, CA
- $33 - $43 an hour
- Contract
- Nursing
- Management
- LVN
- Health insurance
- 401(k) matching
Quick Apply
Utilization Management Nurse, LVN/LPN (Part Time)
NeueHealth —Los Angeles, CA
- $26.35 - $39.53 an hour
- Part-time
- Remote
- Nursing
- LVN
- Mid-level
- Paid holidays
- Health insurance
Quick Apply
RN- Care Review Clinician- UM/Discharge Planning (Remote- CA License Req)
Molina Healthcare —Los Angeles, CA
- $30.37 - $59.21 an hour
- Full-time
- Remote
- RN License
- Mid-level
- Discharge planning
- Health insurance
Discharge Planning Coordinator - Value Based Service Org - Full Time 8 Hour Days (Non-Exempt) (Non-Union)
Keck Medical Center of USC —Los Angeles, CA
- $29.00 - $45.20 an hour
- 8 hour shift
- Background check
- Inpatient
- Mid-level
Case Manager - Utilization Management
West Anaheim Medical Center —Anaheim, CA
- $30.28 - $43.32 an hour
- Full-time
- Acute care
- Hospital
- Computer literacy
- Health insurance
- Dental insurance
1d
Access Coordinator, Care Management, Utilization Management, Full-Time. FTE 0.8, 3:00 PM - 11:30 AM (Location: Whittier)
PIH Health —Downey, CA
- $23.00 - $31.71 an hour
- Full-time
- Hospital
- Computer literacy
- English
Clinical Appeals RN - Remote - M-F working alternating Saturdays
UnitedHealthcare —Cypress, CA
- $28.94 - $51.63 an hour
- Overtime
- Remote
- Nursing
- Microsoft Outlook
- RN License
1d
Appeals RN - Care Management Per Diem - REMOTE
Providence —Torrance, CA
- $57.28 - $88.92 an hour
- 8 hour shift
- Remote
- Nursing
- RN License
- Mid-level
- Paid parental leave
- Paid holidays
16h
Outpatient UM Clinician
MedPOINT Management —Sherman Oaks, CA
- $36 - $48 an hour
- Monday to Friday
- Microsoft Excel
- LVN
- RN License
9d
Care Management Coordinator III (2 Open Positions)
L.A. Care Health Plan —Los Angeles, CA
- $55,245 - $82,867 a year
- Multiple hires
- Writing skills
- Mid-level
- High school diploma or GED
- Wellness program
- Health insurance
9d
Receptionist - Clerk (Case Management)
Hollywood Presbyterian —Los Angeles, CA
- $25.74 - $29.88 an hour
- Full-time
- Acute care
- Microsoft Outlook
- Surgery
Quick Apply
Administrative Assistant - Case Management Per Diem Day
Providence —San Pedro, CA
- $25.00 - $37.98 an hour
- Day shift
- Microsoft Word
- Hospital
- Computer literacy
- Paid parental leave
- Paid holidays
7d
Utilization Management Admissions Liaison RN II (Nights)
L.A. Care Health Plan —Los Angeles, CA
- $88,854 - $142,166 a year
- Full-time
- Acute care
- Nursing
- 7 years
- Wellness program
- Health insurance

I want to receive the latest job alert for utilization management in los angeles ca

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

utilization management jobs near los angeles ca

Utility Manager jobs in Los Angeles, CA

Case Manager jobs in Anaheim, CA

Case Manager jobs in Los Angeles, CA

Licensed Vocational Nurse jobs in Los Angeles, CA

Clinical Nurse jobs in Cypress, CA

Nurse Clinician jobs in Los Angeles, CA

Senior Care Manager jobs in Los Angeles, CA

Registered Nurse jobs in Torrance, CA

Utility Manager jobs in Long Beach, CA

Case Manager jobs in San Pedro, CA

Registered Nurse II jobs in Los Angeles, CA

Customer Success Manager jobs in Houston, TX

Registered Nurse jobs in Springfield, MO

Registered Nurse Manager jobs in Fargo, ND

Registered Dietitian jobs in New York, NY

Fertility Nurse jobs in Cincinnati, OH

Registered Nurse Manager jobs in Webster, NY

Registered Nurse Manager jobs in Sussex County, DE

Registered Nurse Manager jobs in Little Rock, AR

Water Utility jobs in Kenosha, WI

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 jobs in los angeles ca

Utilization Management Outpatient Authorization Nurse

Workers Comp Case Manager

RN, Care Manager Full-time, Day shift

RN, Care Manager

LVN - Utilization Management

Utilization Management Supervisor, Non-Clinical

Revenue Reimbursement Coordinator (Glendale) Full-time, Day

Licensed Practical Nurse - LPN -Utilization Management

Utilization Management Nurse, LVN/LPN (Part Time)

RN- Care Review Clinician- UM/Discharge Planning (Remote- CA License Req)

Discharge Planning Coordinator - Value Based Service Org - Full Time 8 Hour Days (Non-Exempt) (Non-Union)

Case Manager - Utilization Management

Access Coordinator, Care Management, Utilization Management, Full-Time. FTE 0.8, 3:00 PM - 11:30 AM (Location: Whittier)

Clinical Appeals RN - Remote - M-F working alternating Saturdays

Appeals RN - Care Management Per Diem - REMOTE

Outpatient UM Clinician

Care Management Coordinator III (2 Open Positions)

Receptionist - Clerk (Case Management)

Administrative Assistant - Case Management Per Diem Day

Utilization Management Admissions Liaison RN II (Nights)

I want to receive the latest job alert for utilization management in los angeles ca

Related Searches

Explore jobs in more locations

Job Seeker Tools

Employer Tools

Browse

Stay Connected