California Licensed Utilization Management Nurse

Job Summary

A company is looking for a Nurse RN.

Key Responsibilities

• Perform utilization reviews and first-level determination approvals using evidence-based guidelines
• Conduct clinical reviews of claims for medical necessity and ensure compliance with medical policies
• Prepare cases for the Medical Director and maintain quality and productivity metrics for casework

Required Qualifications

• Associate's degree in nursing required; bachelor's degree preferred
• Active Registered Nurse (RN) license in good standing
• Minimum of 5 years of relevant clinical experience in a hospital setting
• Strong clinical background with demonstrated critical thinking skills
• Proficiency with Windows and Excel