California Licensed Nurse Coordinator

Job Summary

To support a managed care health plan, the contract Utilization Management Nurse Coordinator (RN) will work remotely after an initial onsite training period, reviewing outpatient authorization requests, assessing medical necessity, and collaborating with interdisciplinary teams to ensure compliance with healthcare guidelines.

Key responsibilities

• Review outpatient authorization requests and evaluate medical necessity and treatment appropriateness
• Communicate with providers to gather additional clinical information and document findings in the utilization management system
• Collaborate with Case Management and other teams to participate in quality improvement initiatives and ensure regulatory compliance

Required qualifications

• Active/unrestricted Registered Nurse license in California
• 3-5 years of clinical nursing experience with a focus on Utilization Management or case management
• Strong understanding of CMS, Medicare, Medicaid, and commercial health plan regulations
• Experience in reviewing outpatient authorizations and medical necessity determinations
• Ability to work Monday to Friday, 8:00 am to 5:00 pm, with one weekend per month