Top 1507 Rn Jobs in Santa Ana, 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
MDS Coordinator
Intercommunity Care Center —Long Beach, CA
- $39 - $45 an hour
- Full-time
- In person
- Nursing
- Skilled nursing facility
- LVN
- Health insurance
- Dental insurance
Quick Apply
Registered Nurse Manager - MLK BHC Residential
Health Right 360 —Los Angeles, CA
- $126,000 - $136,500 a year
- Full-time
- Background check
- Nursing
- Addiction Medicine
- Commuter assistance
- Paid holidays
Quick Apply
Critical Care Transport RN - Santa Ana
MEDTRANS INC —Santa Ana, CA
- $50 - $72 an hour
- Part-time
- Nursing
- RN License
- PALS Certification
- 401(k)
- Vision insurance
Quick Apply
Associate Dean of Nursing
CNI College —Santa Ana, CA
- From $160,000 a year
- Full-time
- Nursing
- Doctoral degree
- RN License
- Health insurance
- Dental insurance
Quick Apply
12d
RN
South Coast Post Acute —Santa Ana, CA
- $52 an hour
- Nursing
- RN License
- Associate's degree
- Health insurance
- Dental insurance
Quick Apply
Registered Nurse (RN), Pre-Op/PACU - Part Time, Days (8 hour shifts)
CHOC Children's —Orange, CA
- $56.96 - $91.14 an hour
- 8 hour shift
- Nursing
- RN License
- PALS Certification
RN Med Pass
Alta Gardens Care Center —Garden Grove, CA
- $40 - $50 an hour
- Nursing
- RN License
- Associate's degree
- Health insurance
- Dental insurance
Quick Apply
Registered Nurse (RN)
Oakwood Healthcare Services Inc —Irvine, CA
- $100 an hour
- Part-time
- CPR Certification
- RN License
- Hospital
- Flexible schedule
Quick Apply
Registered Nurse
AltaMed Health Services Corporation —Huntington Beach, CA
- From $50 an hour
- Full-time
- Background check
- Spanish
- Nursing
- 403(b) matching
- Paid holidays
10d
Pediatric Registered Nurse
Affirmed Home Care —Los Angeles, CA
- $55 an hour
- 12 hour shift
- Current TB test
- RN License
- BLS Certification
- Flexible schedule
- Referral program
RN Instructor - Tue/Wed/Thu 6 PM to 9 PM
CNI College —Santa Ana, CA
- From $50 an hour
- Part-time
- Classroom
- Nursing
- RN License
Quick Apply
Palliative Care Registered Nurse (RN)
VITAS Healthcare —Irvine, CA
- Full-time
- Bilingual
- Nursing
- RN License
- Disability insurance
- Health insurance
Quick Apply
9d
Registered Nurse
NeuroRestorative —Santa Ana, CA
- $38 - $49 an hour
- 12 hour shift
- CPR Certification
- Nursing
- Patient monitoring
- Health savings account
- Paid holidays
4d
RN - Registered Nurse - School Nurse- Southern Orange County
Ro Health —Laguna Niguel, CA
- $35 - $45 an hour
- Part-time
- RN License
- Pediatrics
- Public school
- Continuing education credits
- Health insurance
Quick Apply
Registered Nurse
NeuroRestorative —Garden Grove, CA
- $38.00 - $47.83 an hour
- 12 hour shift
- CPR Certification
- Nursing
- Patient monitoring
- Paid holidays
- Health insurance
Registered Nurse Administrator
Healthcare Multi-Company —Orange County, CA
- $40.54 - $48.82 an hour
- Full-time
- Background check
- Nursing
- RN License
- Health insurance
- Dental insurance
Quick Apply
RN Director of Nursing |Newport Coast Surgical Institute
SCA Health —Newport Beach, CA
- $160,000 - $185,000 a year
- Full-time
- Nursing
- Surgery
- RN License
- Disability insurance
- Health insurance
Registered Nurse PreOp PACU II, Pool - Memorial Care Surgery Center Laguna Woods
SCA Health —Laguna Woods, CA
- $53 - $55 an hour
- Part-time
- Nursing
- RN License
- PALS Certification
- Disability insurance
- Health insurance
RN / LVN Regional Clinical Liaison
Skilled Wound Care —Orange, CA
- $75,000 - $90,000 a year
- Nursing
- Skilled nursing facility
- Surgery
- Paid holidays
- Health insurance
Quick Apply
1d

I want to receive the latest job alert for rn in santa ana, 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

rn jobs near santa ana, ca

Registered Nurse jobs in Huntington Beach, CA

Associate Dean jobs in Santa Ana, CA

Registered Nurse Pacu jobs in Orange, CA

Mds Coordinator jobs in Long Beach, CA

Registered Nurse jobs in Laguna Niguel, CA

Registered Nurse jobs in Orange County, CA

Registered Nurse jobs in Santa Ana, CA

Registered Nurse jobs in Garden Grove, CA

Registered Nurse Pediatrics jobs in Los Angeles, CA

Registered Nurse jobs in Irvine, CA

Utility Manager jobs in Long Beach, CA

Nursing Instructor jobs in Santa Ana, CA

Registered Nurse jobs in Homestead, FL

Registered Nurse jobs in Altoona, PA

Registered Dietitian jobs in Phoenix, AZ

Registered Nurse jobs in Winston Salem, NC

Registered Nurse jobs in South Bend, IN

Registered Environmental Health Specialist jobs in California

Remote Registered Nurse 1 Year Experience jobs in Anywhere

Dean 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

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

rn jobs in santa ana, ca

Utilization Management Outpatient Authorization Nurse

MDS Coordinator

Registered Nurse Manager - MLK BHC Residential

Critical Care Transport RN - Santa Ana

Associate Dean of Nursing

RN

Registered Nurse (RN), Pre-Op/PACU - Part Time, Days (8 hour shifts)

RN Med Pass

Registered Nurse (RN)

Registered Nurse

Pediatric Registered Nurse

RN Instructor - Tue/Wed/Thu 6 PM to 9 PM

Palliative Care Registered Nurse (RN)

Registered Nurse

RN - Registered Nurse - School Nurse- Southern Orange County

Registered Nurse

Registered Nurse Administrator

RN Director of Nursing |Newport Coast Surgical Institute

Registered Nurse PreOp PACU II, Pool - Memorial Care Surgery Center Laguna Woods

RN / LVN Regional Clinical Liaison

I want to receive the latest job alert for rn in santa ana, ca

Related Searches

Explore jobs in more locations

Job Seeker Tools

Employer Tools

Browse

Stay Connected