California Licensed UM Nurse Coordinator

Job Summary

To support a managed care health plan, the temporary remote UM Nurse Coordinator (RN or LVN) will review outpatient authorization requests, assess medical necessity, and collaborate with interdisciplinary teams, working Monday to Friday from 8 am to 5 pm with one weekend per month.

Key responsibilities

• Review outpatient authorization requests using InterQual and established clinical guidelines
• Evaluate medical necessity and appropriateness of treatment while ensuring compliance with regulations
• Communicate with providers to obtain additional clinical information and document review findings accurately

Required qualifications

• Active/unrestricted Registered Nurse or Licensed Vocational Nurse license in California
• 3-5 years of clinical nursing experience with a focus on Utilization Management or Managed Care
• Experience in reviewing outpatient authorizations and medical necessity determinations
• Strong understanding of CMS, Medicare, Medicaid, and commercial health plan regulations
• Ability to work independently in a fast-paced, member-service oriented environment