Top 350 Utilization review 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
RN Case Manager, Per Diem (rotating weekends)
UCLA Health —Los Angeles, CA
- $98.52 an hour
- Rotating weekends
- Nursing
- RN License
- BLS Certification
Insurance Verifier
UCLA Health —Los Angeles, CA
- $30.47 - $47.85 an hour
- Rotating weekends
- Microsoft Outlook
- Basic math
- Mid-level
9d
Health Care Professional – Utilization Review / First-Level Reviewer
Encompass Health Solutions, Inc. —Los Angeles, CA
- $42 - $45 an hour
- Overtime
- Remote
- LVN
- RN License
- Mid-level
Quick Apply
2d
RN- Care Review Clinician- UM/Discharge Planning (Remote- CA License Req)
Molina Healthcare —Los Angeles, CA
- $30.37 - $59.21 an hour
- Full-time
- Remote
- RN License
- Mid-level
- Discharge planning
- Health insurance
Pre-Registration Representative
UCLA Health —Los Angeles, CA
- $30.36 - $43.49 an hour
- Mid-level
- Typing
- Medical terminology
9d
Chart Auditor - Glendale
Adventist Health —Glendale, CA
- $62.83 - $86.18 an hour
- Full-time
- Nursing
- RN License
- Mid-level
RN - Quality Assurance/Utilization Review - Business Development - Full Time 8hr Covina, California
Emanate Health —Covina, CA
- $52.03 - $80.64 an hour
- 8 hour shift
- RN License
- Customer service
- Computer literacy
- Health insurance
- Dental insurance
Case Manager - Utilization Management
West Anaheim Medical Center —Anaheim, CA
- $30.28 - $43.32 an hour
- Full-time
- Acute care
- Hospital
- Computer literacy
- Health insurance
- Dental insurance
7d
Quality Assurance Clinician
Five Acres —Pasadena, CA
- $72,760 - $118,467 a year
- Full-time
- LMFT
- Master of Social Work
- Writing skills
- AD&D insurance
- Paid holidays
Clinical Consultant - Physician Associate - Remote
UnitedHealthcare —Cypress, CA
- $91,700 - $163,700 a year
- Full-time
- Remote
- Microsoft Outlook
- 5 years
- Pass drug screening
2d
Utilization Specialist
Kheir Clinic —Los Angeles, CA
- $64,540 - $75,248 a year
- Full-time
- Nursing
- Microsoft Excel
- Computer literacy
Quick Apply
1d
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
Utilization Management Admissions Liaison RN II (Nights)
L.A. Care Health Plan —Los Angeles, CA
- $88,854 - $142,166 a year
- Full-time
- Acute care
- Nursing
- 7 years
- Wellness program
- Health insurance
LVN - Quality Assurance/Utilization Review - Business Development - Full Time 8hr
Emanate Health —Covina, CA
- $31.03 - $46.54 an hour
- 8 hour shift
- LVN
- Customer service
- Computer literacy
Quick Apply
2d
Patient Authorization Review Specialist
Ocean View Psychiatric Hospital —Long Beach, CA
- $26 - $28 an hour
- 8 hour shift
- Background check
- Current TB test
- LVN
- Health insurance
- Dental insurance
Quick Apply
Case Management Coordinator - Ambulatory Case Management
Cedars-Sinai —Beverly Hills, CA
- $25.00 - $37.15 an hour
- 8 hour shift
- Word processing
- High school diploma or GED
- Fair chance
- Health insurance
- Dental insurance
11h
Clinical QA Specialist
HELPLINE YOUTH COUNSELING —Huntington Park, CA
- $80,000 - $85,000 a year
- Weekends as needed
- LMFT
- Clean driving record
- Writing skills
Quick Apply
RN - Quality Assurance/Utilization Review - Business Development - Full Time 8hr
Emanate Health —Covina, CA
- $52.03 - $80.64 an hour
- 8 hour shift
- RN License
- Customer service
- Computer literacy
Quick Apply
2d
Discharge Planning Coordinator - Value Based Service Org - Full Time 8 Hour Days (Non-Exempt) (Non-Union)
Keck Medical Center of USC —Los Angeles, CA
- $29.00 - $45.20 an hour
- 8 hour shift
- Background check
- Mid-level
- Outpatient experience

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utilization review jobs near 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

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 jobs in los angeles, ca

Utilization Management Outpatient Authorization Nurse

RN Case Manager, Per Diem (rotating weekends)

Insurance Verifier

Health Care Professional – Utilization Review / First-Level Reviewer

RN- Care Review Clinician- UM/Discharge Planning (Remote- CA License Req)

Pre-Registration Representative

Chart Auditor - Glendale

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

Case Manager - Utilization Management

Quality Assurance Clinician

Clinical Consultant - Physician Associate - Remote

Utilization Specialist

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

Utilization Management Admissions Liaison RN II (Nights)

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

Patient Authorization Review Specialist

Case Management Coordinator - Ambulatory Case Management

Clinical QA Specialist

RN - Quality Assurance/Utilization Review - Business Development - Full Time 8hr

Discharge Planning Coordinator - Value Based Service Org - Full Time 8 Hour Days (Non-Exempt) (Non-Union)

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