Top 55 utilization review 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 ADHC
Seva ADHC LLC —Irvine, CA
- $35 - $43 an hour
- Part-time
- Spanish
- CPR Certification
- Management
Quick Apply
Utilization Management Nurse I, RN
Clever Care Health Plan —Huntington Beach, CA
- $34.98 - $42.85 an hour
- Full-time
- Remote
- Background check
- Spanish
- RN License
- Health insurance
Utilization Review RN - Mid Shift (3pm - 11:30pm)
KPC GLOBAL MEDICAL CENTERS INC. —Santa Ana, CA
- $50 - $85 an hour
- Weekends as needed
- Nursing
- RN License
- Mid-level
Quick Apply
Case Manager (Outpatient Ambulatory Clinic)
City of Hope —Irvine, CA
- $69.97 - $101.46 an hour
- 8 hour shift
- Nursing
- RN License
- BLS Certification
1d
RN Utilization Review - Full-time - REMOTE
Providence —Irvine, CA
- $57.28 - $88.92 an hour
- 8 hour shift
- Remote
- Nursing
- RN License
- Mid-level
- Paid parental leave
- Paid holidays
1d
RN Case Manager
AMN Healthcare —Paramount, CA
- $1,800 - $2,700 a week
- Monday to Friday
- RN License
- BLS Certification
- Mid-level
- Paid jury duty
- Paid holidays
2d
Case Manager, LVN
Coral Cove Post Acute —Long Beach, CA
- $35 - $43 an hour
- Full-time
- LVN
- Mid-level
- Administrative experience
- Health insurance
Quick Apply
8d
Inpatient Review Nurse (Remote, Must have California LVN / RN License)
Alignment Healthcare USA, LLC —Orange, CA
- $77,905 - $116,858 a year
- Full-time
- Remote
- Nursing
- LVN
- RN License
Quick Apply
13d
CLINICAL DOCUMENTATION SPECIALIST 4 HX - Clinical Doc Integrity - FT Days REMOTE
University of California, Irvine —Irvine, CA
- $119,400 - $230,800 a year
- Weekends as needed
- Remote
- Background check
- Nursing
- Customer service
- Health insurance
- Retirement plan
14h
Case Manager - Digestive Health Institute Orange - FT Days
University of California, Irvine —Orange, CA
- $65.58 - $94.61 an hour
- Full-time
- Acute care
- Background check
- Spanish
- Health insurance
- Retirement plan
CLINICAL DOCUMENTATION SPECIALIST 4 HX - Clinical Doc Integrity - FT Days HYBRID
University of California, Irvine —Orange, CA
- $119,400 - $230,800 a year
- Weekends as needed
- Remote
- Background check
- Nursing
- Customer service
- Health insurance
- Retirement plan
Case Manager RN
AHMC Healthcare —Anaheim, CA
- From $39.08 an hour
- Part-time
- Acute care
- Hospital
- Mid-level
RN, Coord, Clinical Admissions - Per-Diem
Long Beach Memorial Medical Center —Long Beach, CA
- $61.98 - $86.73 an hour
- Night shift
- Spanish
- Hospital
- Mid-level
- Health insurance
Registered Nurse Utilization Management Case Manager
US Veterans Health Administration —Long Beach, CA
- $113,143 - $209,521 a year
- Online Application
- Background check
- Nursing
- Doctoral degree
- Paid holidays
- Dental insurance
4d
Clinical Review Nurse - Prior Authorization
Akido —Chino, CA
- $62,400 - $93,600 a year
- LVN
- RN License
- Mid-level
Quick Apply
5d
Case Management - Nurse, Senior- Pregnancy and Postpartum
Blue Shield of California —Long Beach, CA
- $90,860 - $136,290 a year
- Full-time
- Nursing
- RN License
- 5 years
LVN Lead Care Manager
Sowing Seeds Health Inc —Irvine, CA
- $35 an hour
- Full-time
- LVN
- Mid-level
- In-person
- Mileage reimbursement
- Paid holidays
Quick Apply
RN ER Case Manager - PT- 8hrs- Varied
KPC GLOBAL MEDICAL CENTERS INC. —Santa Ana, CA
- $42.89 - $64.33 an hour
- Part-time
- RN License
- Computer literacy
- BLS Certification
- AD&D insurance
- Health insurance
Quick Apply
Utilization Review Coordinator - Full Time, Days (Hybrid-Bellflower)
NOR Healthcare Systems —Bellflower, CA
- $32.70 - $47.20 an hour
- Full-time
- Hybrid work
- LVN
- RN License
- Customer service
7d

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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
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 jobs in irvine ca

Utilization Management Outpatient Authorization Nurse

Registered Nurse ADHC

Utilization Management Nurse I, RN

Utilization Review RN - Mid Shift (3pm - 11:30pm)

Case Manager (Outpatient Ambulatory Clinic)

RN Utilization Review - Full-time - REMOTE

RN Case Manager

Case Manager, LVN

Inpatient Review Nurse (Remote, Must have California LVN / RN License)

CLINICAL DOCUMENTATION SPECIALIST 4 HX - Clinical Doc Integrity - FT Days REMOTE

Case Manager - Digestive Health Institute Orange - FT Days

CLINICAL DOCUMENTATION SPECIALIST 4 HX - Clinical Doc Integrity - FT Days HYBRID

Case Manager RN

RN, Coord, Clinical Admissions - Per-Diem

Registered Nurse Utilization Management Case Manager

Clinical Review Nurse - Prior Authorization

Case Management - Nurse, Senior- Pregnancy and Postpartum

LVN Lead Care Manager

RN ER Case Manager - PT- 8hrs- Varied

Utilization Review Coordinator - Full Time, Days (Hybrid-Bellflower)

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