Top 4 Clinical documentation & utilization review nurses Jobs in Clearlake, Ca

UM Licensed Vocational Nurse (REMOTE)
Medica Talent Group —California
- $33 - $46 an hour
- Temporary
- Remote
- Microsoft Excel
- Microsoft Outlook
- LVN
Quick Apply
10d
Appeals Professional III (Licensed Clinician)
Tanaq Support Services LLC —United States
- Full-time
- Remote
- Nursing
- RN License
- Writing skills
11d
Claims Nurse (Utilization Management / Claims Review) Must have CALIFORNIA license
Dragonfly Global —United States
- $100,000 - $105,000 a year
- Full-time
- Remote
- LVN
- RN License
- Mid-level
- Travel reimbursement
- Health savings account
Quick Apply

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UM Licensed Vocational Nurse (REMOTE)

Medica Talent Group
California

Quick Apply

Job Details

Temporary | Full-time
$33 - $46 an hour
10 days ago

Qualifications

Customer communication
Microsoft Excel
Microsoft Outlook
Medicare
LVN
Managed care
Electronic health records (EHR) management
Customer service
Managed care organization experience
CMS
Regulatory compliance
Word embeddings
HIPAA
Microsoft Office
CMS regulatory compliance
Pre-authorization review for utilization management
Medicare regulations
Utilization management
Clinical program data analysis
Conflict management
Clinical documentation
Resource utilization in healthcare
Health information regulatory compliance
Medicaid regulations
Clinical confidentiality policies
Clinical data analysis

Full Job Description

The LVN Utilization Management Nurse is responsible for reviewing and processing authorization requests to ensure services are medically necessary, appropriate, timely, and consistent with health plan benefits, regulatory requirements, and nationally recognized clinical guidelines. This position reviews inpatient and outpatient services, hospitalizations, home care, treatment plans, and ongoing services while supporting cost-effective, high-quality patient care.

The UM Nurse works closely with Medical Directors, Hospitalists, providers, health plans, hospital partners, and care teams to facilitate timely authorization decisions and coordinate patient care. Responsibilities include verifying member eligibility and benefits, conducting concurrent and retrospective reviews, processing referrals and prior authorizations, coordinating discharge planning, and communicating authorization decisions to providers and members.

The position requires strong knowledge of utilization management processes, Medicare, Medi-Cal, Commercial, CCS, and other government program requirements, as well as familiarity with evidence-based criteria such as Milliman, InterQual, CMS, and specialty-specific guidelines. The UM Nurse must maintain accurate documentation, meet required turnaround times, protect patient confidentiality, and comply with HIPAA and applicable federal and state regulations.

Minimum Qualifications:

Current, valid Licensed Vocational Nurse (LVN) license.
Minimum of 2 years of managed care experience.
Experience using electronic medical records, authorization systems, and Microsoft Office applications, including Word, Excel, and Outlook.
Knowledge of utilization management, pre-authorizations, reimbursement regulations, and applicable federal and state requirements.
Strong communication, customer service, interpersonal, problem-solving, and conflict-resolution skills.
Ability to work collaboratively with diverse internal and external stakeholders.
Strong attention to detail and ability to analyze and interpret clinical and operational data.
Knowledge of DOFRs, delegation agreements, authorization matrices, and health plan requirements preferred.
Commitment to HIPAA compliance, privacy, and confidentiality standards.

Key Responsibilities:

Review and process referral and authorization requests within established turnaround time requirements.
Evaluate medical necessity and level of care using applicable clinical and evidence-based guidelines.
Verify member eligibility and benefits and communicate authorization decisions to providers and members.
Monitor ongoing services for medical necessity, appropriateness, and cost effectiveness.
Coordinate with Medical Directors, referral specialists, providers, hospitals, and health plans to facilitate timely decisions.
Process and coordinate Letters of Agreement (LOAs) for non-contracted providers and facilities, when applicable.
Conduct concurrent and retrospective reviews, discharge planning, and prior authorization/pre-certification activities as assigned.
Maintain accurate and timely documentation in the Medical Management system.
Stay current on utilization management regulations, health plan requirements, and applicable clinical guidelines.
Develop positive working relationships with internal and external customers while supporting high-quality, cost-effective patient care.

***TEMP POSITION - ASSIGNMENT ENDS 10/31/26***

Pay: $33.00 - $46.00 per hour

Experience:

Managed care: 2 years (Required)
Microsoft Office: 1 year (Required)

License/Certification:

LVN (Required)

Location:

California (Required)

Work Location: Remote

Quick Apply

Refine Your Search

clinical documentation & utilization review nurses jobs in clearlake, ca

UM Licensed Vocational Nurse (REMOTE)

Appeals Professional III (Licensed Clinician)

Claims Nurse (Utilization Management / Claims Review) Must have CALIFORNIA license

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I want to receive the latest job alert for clinical documentation & utilization review nurses in clearlake, ca

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