Top 861 Utilization management 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
- From $67,000 a year
- Full-time
- Nursing
- LVN
- HIPAA
- Health insurance
- Dental insurance
Quick Apply
Mental Health Case Manager - Office of Diversion and Reentry
Alcott Center For Mental Health Services —Culver City, CA
- $24 - $26 an hour
- Full-time
- Spanish
- Clean driving record
- Military
- Health insurance
- Dental insurance
Quick Apply
RN Case Manager - Surgery Services
UCLA Health —Los Angeles, CA
- $65.53 - $84.75 an hour
- Nursing
- Surgery
- RN License
RN Case Manager - Medicine ICU
UCLA Health —Los Angeles, CA
- $65.53 - $84.75 an hour
- Nursing
- RN License
- BLS Certification
Regional Director of Pharmacy–Infusion/Oncology Operations
UCLA Health —Los Angeles, CA
- $162,200 - $392,000 a year
- Monday to Friday
- Travel
- Mentoring
- Organizational skills
Bilingual Healthcare Call Center Representative (Spanish Speaking)
Pair Team —Los Angeles, CA
- $25 an hour
- Email
- Remote
- Background check
- Spanish
- HIPAA
- Dental insurance
- 401(k)
Quick Apply
Utilization Management Nurse - RN
NeueHealth —Los Angeles, CA
- $74,260.46 - $111,390.70 a year
- Full-time
- Remote
- Nursing
- Microsoft Excel
- Microsoft Outlook
- Paid holidays
- Health insurance
Quick Apply
Concurrent Utilization Review Nurse, RN
NeueHealth —Los Angeles, CA
- $74,286.15 - $111,429.23 a year
- Remote
- Nursing
- RN License
- Mid-level
- Paid holidays
- Health insurance
Quick Apply
Inpatient/ Primary Care Physician
Kedren Community Health Center Inc —Los Angeles, CA
- $185,000 a year
- On call
- CPR Certification
- Medicine
- BLS Certification
Quick Apply
Physical Therapist (PT)
Berkley Post-Acute —Los Angeles, CA
- $50 - $55 an hour
- Full-time
- CPR Certification
- Skilled nursing facility
- Doctoral degree
- Disability insurance
- Health insurance
Quick Apply
Physical Therapist (PT)
Berkley West Healthcare Center —Santa Monica, CA
- $120,640 - $135,200 a year
- Part-time
- CPR Certification
- Skilled nursing facility
- Doctoral degree
- Disability insurance
- Health insurance
Quick Apply
Director of Clinical Operations - Dialysis
American Renal Care, LLC —Mission Hills, CA
- $150,000 - $195,000 a year
- Full-time
- Spanish
- Nursing
- RN License
- Health insurance
- Dental insurance
Quick Apply
9d
Field Medicine Physician Assistant
Valley Community Healthcare —San Fernando Valley, CA
- $170,000 - $185,000 a year
- Full-time
- Microsoft Excel
- BLS Certification
- Urgent Care
Quick Apply
Bilingual Clinical Supervisor (LMFT or LCSW and Spanish Speaking Required)
CSC South Bay —Torrance, CA
- $45 an hour
- Part-time
- Hybrid work
- LMFT
- Spanish
- Licensed Clinical Social Worker
- 401(k)
- Paid time off
Quick Apply
8d
Field Medicine Nurse Practitioner
Valley Community Healthcare —San Fernando Valley, CA
- $170,000 - $185,000 a year
- Full-time
- Spanish
- Nursing
- Microsoft Excel
Quick Apply
Physician - Obstetrics
Gracelight Community Health —Los Angeles, CA
- $212,049 - $339,241 a year
- Part-time
- Spanish
- CPR Certification
- Medicine
Quick Apply
Nurse Manager, Perioperative Services
The Roxbury Institute —Beverly Hills, CA
- $120,000 - $145,000 a year
- Full-time
- Nursing
- Surgery
- RN License
- Free parking
- Paid holidays
Quick Apply
Licensed Clinical Social Worker
Partners in Care Foundation, Inc. —San Fernando, CA
- $37 - $43 an hour
- Full-time
- Hybrid work
- Microsoft Outlook
- Licensed Clinical Social Worker
- Mid-level
- Health savings account
- Health insurance
Quick Apply
2d
Experienced Hospice LVN Case Manage-Full Time (Anaheim/Orange County)
Healing Hands Hospice Care, Inc —Anaheim, CA
- $30 - $35 an hour
- Full-time
- Background check
- Spanish
- LVN
- Paid time off
Quick Apply
LCSW/LMFT Clinical Supervisor
MADISON AVENUE SUPPORT SERVICE —Culver City, CA
- $125,000 a year
- Full-time
- Background check
- LMFT
- Management
- Health insurance
- 401(k)
Quick Apply

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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 management jobs in los angeles, ca

Utilization Management Outpatient Authorization Nurse

Mental Health Case Manager - Office of Diversion and Reentry

RN Case Manager - Surgery Services

RN Case Manager - Medicine ICU

Regional Director of Pharmacy–Infusion/Oncology Operations

Bilingual Healthcare Call Center Representative (Spanish Speaking)

Utilization Management Nurse - RN

Concurrent Utilization Review Nurse, RN

Inpatient/ Primary Care Physician

Physical Therapist (PT)

Physical Therapist (PT)

Director of Clinical Operations - Dialysis

Field Medicine Physician Assistant

Bilingual Clinical Supervisor (LMFT or LCSW and Spanish Speaking Required)

Field Medicine Nurse Practitioner

Physician - Obstetrics

Nurse Manager, Perioperative Services

Licensed Clinical Social Worker

Experienced Hospice LVN Case Manage-Full Time (Anaheim/Orange County)

LCSW/LMFT Clinical Supervisor

I want to receive the latest job alert for utilization management in los angeles, ca

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