California Licensed Clinical Review Nurse

Job Summary

A company is looking for a Utilization Review Nurse, focused on appeals, grievances, medical necessity review, and utilization management.

Key Responsibilities

• Conduct clinical reviews of appeals, grievances, and disputed cases related to medical necessity and level of care
• Review medical records across various stages including prospective, concurrent, inpatient, and retrospective
• Document clinical findings and generate written correspondence for providers, members, and regulatory entities

Required Qualifications

• Active, unrestricted California RN license
• Minimum 3 years of acute care clinical experience
• Minimum 2 years of experience in appeals and grievances casework
• Strong experience in utilization review and quality management
• Working knowledge of InterQual, MCG, and regulatory compliance