California Licensed Appeals Supervisor

Job Summary

Supervising a team of clinical reviewers, the full-time California Licensed Appeals Supervisor will manage day-to-day activities in utilization management, ensuring compliance and quality standards while working remotely.

Key responsibilities

• Oversees Prior Authorization, Concurrent Review, and Retrospective Review processes to ensure appropriate care for members
• Collaborates with the utilization management team to resolve complex member care issues and identifies opportunities for process improvement
• Monitors team performance, provides coaching, and assists with onboarding and training of new team members

Required qualifications

• Graduate of an Accredited School of Nursing or Bachelor's degree with 4+ years of related experience
• Current and active RN license from the state of California is strongly preferred
• 3 - 5 years of direct work experience in appeals processes and utilization management principles in managed care environments is preferred
• Certification as a Managed Care Nurse (CMCN) within 1-1/2 years is required for specific roles
• Must possess US citizenship and current National Agency Check government security clearance for certain positions