Top 68 Utilization review nurse lvn Jobs in California

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
LVN Nurse Case Manager
Centric Healthcare Services —Bakersfield, CA
- $30 - $35 an hour
- Full-time
- Nursing
- Skilled nursing facility
- LVN
- Health insurance
- Dental insurance
Quick Apply
SBS - Utilization Authorization Coordinator (UM Review Nurse)
Choice Medical Group —Camarillo, CA
- $48 - $55 an hour
- Full-time
- LVN
- RN License
- Mid-level
- Health insurance
- Dental insurance
Quick Apply
Utilization Management Nurse, LVN/LPN
NeueHealth —Los Angeles, CA
- $26.35 - $39.53 an hour
- Remote
- Nursing
- LVN
- RN License
- Paid holidays
- Health insurance
Quick Apply
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
UM Review Nurse
Astrana Health, Inc. —California
- $34 - $47 an hour
- Overtime
- Microsoft Word
- Microsoft Excel
- Microsoft Outlook
Quick Apply
Utilization Management Nurse, Lead (Inpatient | Remote | Must have California LVN / RN License)
Alignment Healthcare USA, LLC —Orange, CA
- $85,696 - $128,543 a year
- Full-time
- Remote
- Nursing
- LVN
- RN License
Quick Apply
Clinical Review Nurse - Prior Authorization
Akido —Chino, CA
- $62,400 - $93,600 a year
- LVN
- RN License
- Mid-level
Quick Apply
Utilization Review Tech III
Sutter Health —San Mateo, CA
- $47.94 - $57.52 an hour
- 8 hour shift
- Nursing
- LVN
- Psychiatry
6d
UM Nurse Reviewer, LVN - Bakersfield 1.2
Universal Healthcare MSO LLC —Bakersfield, CA
- $31.00 - $54.18 an hour
- Full-time
- Nursing
- LVN
- RN License
- Health insurance
- Dental insurance
COORDINATOR, UM (LVN)
Pomona Valley Hospital Medical Center —Pomona, CA
- $35.95 - $50.59 an hour
- Full-time
- LVN
- Hospital
- Mid-level
UM Nurse Reviewer
Astiva Health —Orange, CA
- $75,000 - $95,000 a year
- Nursing
- LVN
- Basic math
- Health insurance
- Dental insurance
Quick Apply
13d
Clinical Review Nurse – Medical Claims
MedPOINT Management —Woodland Hills, CA
- $36 - $48 an hour
- LVN
- RN License
- Mid-level
Grievance & Appeals Nurse Specialist
CalOptima —Orange, CA
- Weekends as needed
- Background check
- Spanish
- Microsoft Outlook
- Tuition reimbursement
- Paid time off
LVN - SNF Quality & Clinical Operations
Community Health Centers of America —Fair Oaks, CA
- $40 - $45 an hour
- Full-time
- Nursing
- Skilled nursing facility
- Current TB test
Quick Apply
Utilization Management Clinical Trainer (Hybrid Remote)
Alignment Healthcare USA, LLC —Orange, CA
- $77,905 - $116,858 a year
- Full-time
- Hybrid work
- Nursing
- LVN
- RN License
- Travel reimbursement
Quick Apply
LVN Licensed Vocational Nurse
Northvine Post Acute Care —Santa Rosa, CA
- $38 - $44 an hour
- Full-time
- Nursing
- LVN
- HIPAA
Quick Apply
Concurrent Case Management LVN
LSMA Management Inc —San Bernardino, CA
- $35 - $40 an hour
- Full-time
- Nursing
- LVN
- BLS Certification
LVN - Quality Assurance/Utilization Review - Business Development - Full Time 8hr Covina, California
Emanate Health —Covina, CA
- $31.03 - $46.54 an hour
- 8 hour shift
- LVN
- Customer service
- Computer literacy
Case Manager (LVN or RN)
Astrana Health, Inc. —Monterey Park, CA
- $31 - $45 an hour
- Email
- Hybrid work
- Microsoft Excel
- Microsoft Outlook
- LVN
Quick Apply
11d

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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 review nurse lvn jobs in california

Utilization Management Outpatient Authorization Nurse

LVN Nurse Case Manager

SBS - Utilization Authorization Coordinator (UM Review Nurse)

Utilization Management Nurse, LVN/LPN

CA Utilization Review Nurse I

UM Review Nurse

Utilization Management Nurse, Lead (Inpatient | Remote | Must have California LVN / RN License)

Clinical Review Nurse - Prior Authorization

Utilization Review Tech III

UM Nurse Reviewer, LVN - Bakersfield 1.2

COORDINATOR, UM (LVN)

UM Nurse Reviewer

Clinical Review Nurse – Medical Claims

Grievance & Appeals Nurse Specialist

LVN - SNF Quality & Clinical Operations

Utilization Management Clinical Trainer (Hybrid Remote)

LVN Licensed Vocational Nurse

Concurrent Case Management LVN

LVN - Quality Assurance/Utilization Review - Business Development - Full Time 8hr Covina, California

Case Manager (LVN or RN)

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