Top 328 Outpatient nurse Jobs in Irvine, 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
Registered Nurse OR Circulator -Multispecialty
Bay Area Surgical Management LLC —Tustin, CA
- $63 - $65 an hour
- Full-time
- Background check
- Nursing
- Surgery
- Health insurance
- Dental insurance
Quick Apply
RN - Infusion Per-diem Day
Providence Health and Services —Orange, CA
- $54.05 - $83.90 an hour
- Full-time
- Nursing
- RN License
- Hospital
- Paid parental leave
- Paid holidays
3d
Infusion Nurse
Soleo Health Inc —Huntington Beach, CA
- $42 - $52 an hour
- Weekends as needed
- Nursing
- Microsoft Outlook
- RN License
- Mileage reimbursement
- Paid parental leave
Quick Apply
Registered Nurse (RN), WOC Nurse Home Health, Full-Time, 8:00 AM - 5:00 PM
PIH Health —Whittier, CA
- $51.73 - $85.36 an hour
- Full-time
- Nursing
- RN License
- Computer literacy
Clinic Nurse (RN): Hoag OB/GYN, Newport Beach
Hoag Health System —Newport Beach, CA
- Full-time
- Nursing
- Microsoft Outlook
- RN License
2d
RN - Infusion Per-diem Day
Providence —Orange, CA
- $54.05 - $83.90 an hour
- Day shift
- Nursing
- RN License
- Hospital
- Paid parental leave
- Paid holidays
2d
Vocational Nurse, Per Diem
University of California, Irvine —Irvine, CA
- $41.08 an hour
- Extended hours
- Background check
- School experience
- CPR Certification
- COVID-19 protective measures
- Health insurance
13d
Registered Nurse (RN) - Psych Acute
Garden Grove Hospital Medical Center —Garden Grove, CA
- $49.82 - $62.22 an hour
- Part-time
- Acute care
- RN License
- BLS Certification
- Health insurance
- Dental insurance
3d
Registered Nurse (RN) Pre Admission Testing , Full Time
Corona Regional Medical Center —Corona, CA
- $50.50 - $73.81 an hour
- Full-time
- Acute care
- Nursing
- Surgery
- Continuing education credits
- Health insurance
12d
Nurse Educator - Inservice Education Part-time Day
Providence —Orange, CA
- $57.28 - $88.92 an hour
- 8 hour shift
- Nursing
- RN License
- BLS Certification
- Paid parental leave
- Paid holidays
Clinical Appeals Nurse (Remote | Must have California LVN / RN License)
Alignment Healthcare USA, LLC —Orange, CA
- $77,905 - $116,858 a year
- Full-time
- Remote
- Microsoft Word
- Spanish
- Nursing
Quick Apply
RN - Interventional Radiology FT Day
Providence —Mission Viejo, CA
- $54.05 - $83.90 an hour
- Full-time
- Nursing
- RN License
- BLS Certification
- Paid parental leave
- Paid holidays
Clinical Nurse II: Chemical Dependency
Hoag Health System —Newport Beach, CA
- Nursing
- RN License
- BLS Certification
Clinical Nurse III - Infusion Clinic, Full-time
City of Hope —Irvine, CA
- $63.81 - $92.53 an hour
- Full-time
- Nursing
- Vital signs
- RN License
10d
Registered Nurse (RN) – Ambulatory Surgery Center (ASC)
Foothill Surgical Institute, LLC —Lake Forest, CA
- From $45 an hour
- PRN
- Medication administration
- Surgery
- RN License
Quick Apply
10d
Registered Nurse (RN) - Psych Acute
Huntington Beach Hospital —Huntington Beach, CA
- $46.52 - $62.54 an hour
- Full-time
- Acute care
- RN License
- BLS Certification
- Health insurance
- Dental insurance
2d
Registered Nurse (RN)
Modwella CA —Orange County, CA
- $60 - $120 an hour
- Choose your own hours
- RN License
- BLS Certification
- Mid-level
- Employee discount
- Flexible schedule
Quick Apply
Nurse Navigator - ACC - Breast Center - FT Days
University of California, Irvine —Irvine, CA
- $68.86 - $100.34 an hour
- Full-time
- Background check
- Nursing
- RN License
- Health insurance
- Retirement plan
1d
Registered Nurse (RN) Urgent Care, Per Diem, 10 Hour, 9:30am-8:30pm
PIH Health —Whittier, CA
- $50.50 - $81.04 an hour
- PRN
- CPR Certification
- Nursing
- RN License
3d

I want to receive the latest job alert for outpatient nurse in irvine, 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

outpatient nurse jobs near irvine, 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

outpatient nurse jobs in irvine, ca

Utilization Management Outpatient Authorization Nurse

Registered Nurse OR Circulator -Multispecialty

RN - Infusion Per-diem Day

Infusion Nurse

Registered Nurse (RN), WOC Nurse Home Health, Full-Time, 8:00 AM - 5:00 PM

Clinic Nurse (RN): Hoag OB/GYN, Newport Beach

RN - Infusion Per-diem Day

Vocational Nurse, Per Diem

Registered Nurse (RN) - Psych Acute

Registered Nurse (RN) Pre Admission Testing , Full Time

Nurse Educator - Inservice Education Part-time Day

Clinical Appeals Nurse (Remote | Must have California LVN / RN License)

RN - Interventional Radiology FT Day

Clinical Nurse II: Chemical Dependency

Clinical Nurse III - Infusion Clinic, Full-time

Registered Nurse (RN) – Ambulatory Surgery Center (ASC)

Registered Nurse (RN) - Psych Acute

Registered Nurse (RN)

Nurse Navigator - ACC - Breast Center - FT Days

Registered Nurse (RN) Urgent Care, Per Diem, 10 Hour, 9:30am-8:30pm

I want to receive the latest job alert for outpatient nurse in irvine, ca

Related Searches

Explore jobs in more locations

Job Seeker Tools

Employer Tools

Browse

Stay Connected