Top 36 Utilization management nurse Jobs in Riverside, Ca

LVN Utilization Management Review Nurse (Hybrid)
Golden Coast MSO —Riverside, CA
- $30 - $40 an hour
- Part-time
- Hybrid work
- Skilled nursing facility
- LVN
- Mid-level
- Health insurance
- Paid time off
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Prior Auth Nurse
REGAL MEDICAL GROUP, INC —San Bernardino, CA
- $37 - $50 an hour
- Full-time
- Nursing
- Microsoft Outlook
- RN License
- Continuing education credits
- Paid holidays
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CA Utilization Review Nurse I
CorVel Corporation —Rancho Cucamonga, CA
- $30.64 - $45.80 an hour
- Full-time
- Remote
- Nursing
- LVN
- RN License
- Health savings account
- Disability insurance
Quick Apply
Registered Nurse - Utilization and Care Transitions
Neighborhood Healthcare —Riverside, CA
- $50.10 - $75.10 an hour
- Monday to Friday
- CPR Certification
- Nursing
- Skilled nursing facility
- Health insurance
- Dental insurance
Quick Apply
RN Case Manager
Institute on Aging —San Bernardino, CA
- $90,000 - $100,000 a year
- Full-time
- Remote
- Background check
- Nursing
- Addiction Medicine
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Care Manager, ER
Redlands Community Hospital —Redlands, CA
- $49.98 - $79.26 an hour
- Full-time
- CPR Certification
- Nursing
- RN License
4d
Provider Quality Review Nurse, RN
Inland Empire Health Plan —Rancho Cucamonga, CA
- $91,249.60 - $120,910.40 a year
- Full-time
- Hybrid work
- Nursing
- RN License
- Word processing
- Disability insurance
- Health insurance
Prior Auth Nurse Temp
REGAL MEDICAL GROUP, INC —San Bernardino, CA
- $37.50 - $50.00 an hour
- Temporary
- Nursing
- Microsoft Outlook
- RN License
Quick Apply
Clinical Review Nurse - Prior Authorization
Akido —Chino, CA
- $62,400 - $93,600 a year
- LVN
- RN License
- Mid-level
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COORDINATOR, UM (LVN)
Pomona Valley Hospital Medical Center —Pomona, CA
- $35.95 - $50.59 an hour
- Full-time
- LVN
- Hospital
- Mid-level
Case Manager (RN) - Utilization Management
Chino Valley Medical Center —Chino, CA
- $43.25 - $58.21 an hour
- Full-time
- Nursing
- RN License
- Hospital
- Health insurance
- Dental insurance
Care Manager-RN
Loma Linda University Health —Redlands, CA
- $59.77 - $80.39 an hour
- Full-time
- Spanish
- Nursing
- Microsoft Outlook
8d
Case Manager
Loma Linda University Health —Loma Linda, CA
- $59.18 - $79.60 an hour
- Full-time
- Spanish
- Nursing
- Microsoft Outlook
Case Manager - RN. Children's Hospital
Loma Linda University Health —Loma Linda, CA
- $59.18 - $79.60 an hour
- Full-time
- Nursing
- RN License
- Customer service
7d
Post-Acute Case Manager
LSMA Management Inc —San Bernardino, CA
- $35 - $38 an hour
- Full-time
- Acute care
- Nursing
- Skilled nursing facility
Clinical Director of Nursing Services II - RUHS - UR-Case Management
County of Riverside —Moreno Valley, CA
- $148,038.16 - $261,634.49 a year
- Monday to Friday
- Background check
- Nursing
- RN License
- Paid holidays
- Disability insurance
RN Case Manager
Riverside Community Hospital —Riverside, CA
- $64 - $91 an hour
- Full-time
- Mid-level
- Critical & Intensive Care
- 2 years
- Employee stock purchase plan
- Disability insurance
Quick Apply
Coordinator-UtilizationMgt/Rvw. PM TEMPORARY 6/21-12/18/26
Loma Linda University Health —Loma Linda, CA
- $26.03 - $32.51 an hour
- Full-time
- Basic math
- HIPAA
- Mid-level
Hospice On-call Registered Nurse (RN)
Loma Linda University Hospice —Loma Linda, CA
- $50 - $60 an hour
- Part-time
- Bilingual
- Skilled nursing facility
- Medication administration
- Health insurance
- Dental insurance
Quick Apply
Nursing House Supervisor
AHMC Healthcare —Riverside, CA
- From $55 an hour
- On call
- Nursing
- RN License
- PALS Certification

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utilization management nurse jobs near riverside, ca

LVN Utilization Management Review Nurse (Hybrid)

Golden Coast MSO -
Riverside, CA

Quick Apply

Job Details

Part-time | Full-time
$30 - $40 an hour

Benefits

Health insurance
Paid time off

Qualifications

Computer operation
Medicare
LVN
CMS
High school diploma or GED
ICD-9
ICD-10
CMS regulatory compliance
Medicare regulations
Utilization management
Resource utilization in healthcare
Computer skills
Clinical documentation standards

Full Job Description

Position Summary/Position

Under the general direction of the Operations Director with supervision and accountability to the Medical Director and within the LVN scope of practice, the LVN UM Review Nurse is responsible for working directly with Providers, contracted entities and vendors to ensure coordinated, continuous quality healthcare for plan embers.

This position is available as in-office or hybrid, allowing for flexibility based on business needs and employee preference. Additionally, it provides opportunities for growth and leadership development.

Major Functions (Duties And Responsibilities)

Responsible for gathering of clinical documentation to assist the Medical Director with decision of prospective/pre-service, concurrent or retrospective reviews based on clinical criteria for appropriateness of outpatient and inpatient services and care.
Under the supervision and direction of the medical director, assist in preparation of service denial letters and notices. Familiarity with Apollo Managed Care Guidelines is preferred. Strong written communication skills are required.
Responsible for concurrent hospital, SNF, and home health review. Receive regular care updates from attending providers and care coordinators. Review admission for medical necessity and appropriate average length of stay and prepare recommendations for medical director.
Arrange transition of care between patient settings including discharging and receiving coordination and referral submission and approval.
Responsible for preparation of regular status reports and updates to partnered IPA and physician groups. Participate in preparation of delegated reports for payers and regulatory bodies.
Works collaboratively with the UM team to ensure regulatory timeframes are upheld for authorization of concurrent, outpatient or ancillary services as per approved clinical criteria, including but not limited to, specialist referrals, outpatient surgery, durable medical equipment, home health, etc.
Serves as a resource for Golden Coast MSO Member and Provider Service departments for utilization management, referral, and continuity of care issues.
Works with Contracts Department to identify gaps in provider network.
Responsible for assisting with the letter of agreement process when referring to Members to out-of-network providers.
Responsible for timely and appropriate documentation in the medical management system.
Assist with identifying potential cases for Case Management, Disease Management, Health Education and/or quality of care issues and making appropriate referrals when needed.
Responsible for working with Team Members to support the goals of the department and the vision of the organization.
Receive phone calls and assist with provider requests for authorization status updates, extensions, and modifications.
Process all authorizations through Quick Cap managed care processing software.

Required Experience

Three (3) or more years of utilization management experience in a health care delivery setting.

Preferred Experience

Experience in an HMO, IPA, or Managed Care setting preferred.

Education Qualifications

High school diploma or GED required.

Preferred Education

Associates of Bachelor's degree.

Professional Licenses

Possession of an active, unrestricted, and unencumbered Vocational Nurse (LVN) license issued by the California BRN required.

Knowledge Requirement

Knowledge of Title 22, Title 10, DMHC, DHCS, and CMS regulatory requirements. ICD-9/10 and CPT coding.

Knowledge of capitated managed care environment helpful. MediCal, Medicare and other state/federal Program & Regulations.

Knowledge of division of financial responsibility (DOFR) contracts preferred.

Knowledge of benefit plans preferred.

Skills Requirement

Computer skills required and proficiency in Windows applications preferred.

Proficiency in Excel strongly preferred.

Excellent communication and interpersonal skills.

Strong organizational skills.

Professional demeanor.

Commitment to Team Culture.

Working Conditions

Must be able to sit, walk, and stand. Must be able to use hands and fingers to operate equipment including, but not limited to, computers, phones, and stationery. Must occasionally lift up to 25 pounds. Must be able to view screens and monitors 90% of the time while stationary.

Work Environment

We offer a hybrid work model, allowing employees to work in-office and remotely as agreed upon with management.

About Golden Coast MSO

Golden Coast MSO was founded to create a proactive, easy to work with management services organization. Seeing an opportunity to provide exceptional professional services, our team came together to design an MSO that prioritizes provider and patient needs.

We are an expanding organization looking to build a team committed to excellence and professional growth. We value proactive and honest individuals who can create simple and effective systems which place patients' needs first.

Job Types: Full-time, Part-time

Pay: $30.00 - $40.00 per hour

Benefits:

Health insurance
Paid time off

Work Location: Hybrid remote in Riverside, CA 92501

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Refine Your Search

utilization management nurse jobs in riverside, ca

LVN Utilization Management Review Nurse (Hybrid)

Prior Auth Nurse

CA Utilization Review Nurse I

Registered Nurse - Utilization and Care Transitions

RN Case Manager

Care Manager, ER

Provider Quality Review Nurse, RN

Prior Auth Nurse Temp

Clinical Review Nurse - Prior Authorization

COORDINATOR, UM (LVN)

Case Manager (RN) - Utilization Management

Care Manager-RN

Case Manager

Case Manager - RN. Children's Hospital

Post-Acute Case Manager

Clinical Director of Nursing Services II - RUHS - UR-Case Management

RN Case Manager

Coordinator-UtilizationMgt/Rvw. PM TEMPORARY 6/21-12/18/26

Hospice On-call Registered Nurse (RN)

Nursing House Supervisor

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