Top 2032 Registered nurse Jobs in Wilmington, 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
Ambulatory RN Clinical Supervisor
Martin Luther King, Jr. Community Hospital —Los Angeles, CA
- $55.63 - $86.23 an hour
- 8 hour shift
- Background check
- Spanish
- Nursing
- Wellness program
- 403(b) matching
Quick Apply
RN - MedSurg Acute (Full Time, Night Shift)
Adventist Health —Los Angeles, CA
- $54.20 - $74.34 an hour
- Full-time
- Acute care
- CPR Certification
- Nursing
RN - Obstetrics Acute (Full-time, Night Shift)
Adventist Health —Los Angeles, CA
- $54.20 - $74.34 an hour
- Full-time
- Acute care
- CPR Certification
- Nursing
RN, Care Manager
Adventist Health —Los Angeles, CA
- $57.50 - $78.87 an hour
- Full-time
- Acute care
- Nursing
- Addiction Medicine
RN – Oncology, Torrance
UCLA Health —Torrance, CA
- $70.59 - $106.80 an hour
- Nursing
- RN License
- BLS Certification
3d
Clinical Appeals RN - Remote - M-F working alternating Saturdays
UnitedHealthcare —Cypress, CA
- $28.94 - $51.63 an hour
- Overtime
- Remote
- Nursing
- Microsoft Outlook
- RN License
2d
RN New grads OK
Long Beach Healthcare Center —Long Beach, CA
- $45 - $55 an hour
- Part-time
- CPR Certification
- Nursing
- Skilled nursing facility
- Health insurance
- Dental insurance
Quick Apply
RN - GI Lab - Days Full Time
Providence —Torrance, CA
- $60.41 - $81.46 an hour
- 8 hour shift
- Nursing
- RN License
- BLS Certification
- Paid parental leave
- Paid holidays
RN GI Services
St Mary Medical Center —Long Beach, CA
- $58.70 - $73.30 an hour
- Full-time
- Acute care
- RN License
- Hospital
Registered Nurse (RN)- PACU
Newport Plaza Surgical Center —Newport Beach, CA
- $55 - $65 an hour
- Full-time
- Surgery
- RN License
- Internal Medicine
- Health insurance
- Dental insurance
Quick Apply
Acute Dialysis RN
U.S. Renal Care —Long Beach, CA
- $47.21 - $70.82 an hour
- Full-time
- Acute care
- CPR Certification
- Patient monitoring
9d
RN, Care Manager (Per Diem, Day Shift)
Adventist Health —Los Angeles, CA
- $57.50 - $78.87 an hour
- Part-time
- Acute care
- Nursing
- Addiction Medicine
RN - NICU (Full-time, Night Shift)
Adventist Health —Los Angeles, CA
- $54.20 - $74.34 an hour
- Full-time
- CPR Certification
- Nursing
- Management
RN - IV Wellness Clinic Per Diem
Hydration Room —Torrance, CA
- $50 - $60 an hour
- Part-time
- Nursing
- Management
- RN License
- Health insurance
- Dental insurance
Quick Apply
14d
Acute Dialysis Nurse (Full Time)
American Dialysis Services —Norwalk, CA
- $65 an hour
- Extended hours
- Acute care
- Background check
- RN License
Quick Apply
RN - IV Wellness Clinic -Per Diem
Hydration Room —Santa Monica, CA
- $50 - $60 an hour
- Part-time
- Nursing
- Management
- RN License
- Health insurance
- Dental insurance
Quick Apply
14d
RN
Nextaff —Paramount, CA
- $45 - $55 an hour
- Evenings as needed
- RN License
- BLS Certification
- Mid-level
- Travel reimbursement
RN Case Manager
AMN Healthcare —Downey, CA
- $1,800 - $2,700 a week
- Monday to Friday
- Acute care
- RN License
- Hospital
- Paid jury duty
- Paid holidays
Case Manager - RN Full Time Day Shift
Memorial Hospital of Gardena —Gardena, CA
- $51.88 - $76.28 an hour
- Full-time
- Nursing
- RN License
- Hospital
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 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

registered nurse jobs in wilmington, ca

Utilization Management Outpatient Authorization Nurse

Ambulatory RN Clinical Supervisor

RN - MedSurg Acute (Full Time, Night Shift)

RN - Obstetrics Acute (Full-time, Night Shift)

RN, Care Manager

RN – Oncology, Torrance

Clinical Appeals RN - Remote - M-F working alternating Saturdays

RN New grads OK

RN - GI Lab - Days Full Time

RN GI Services

Registered Nurse (RN)- PACU

Acute Dialysis RN

RN, Care Manager (Per Diem, Day Shift)

RN - NICU (Full-time, Night Shift)

RN - IV Wellness Clinic Per Diem

Acute Dialysis Nurse (Full Time)

RN - IV Wellness Clinic -Per Diem

RN

RN Case Manager

Case Manager - RN Full Time Day Shift

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