California Licensed Utilization Management Nurse

Job Summary

To support healthcare quality, the full-time California Licensed Utilization Management Nurse will conduct concurrent clinical reviews to assess medical necessity for inpatient services, collaborate with the Medical Director on complex cases, and communicate with healthcare providers and payers to ensure compliance with health plan policies.

Key Responsibilities

• Conduct timely reviews of inpatient and skilled nursing services to determine medical necessity and appropriateness based on clinical guidelines
• Collaborate with the Medical Director on complex cases and provide comprehensive clinical summaries for further assessment
• Process authorization requests and communicate with healthcare providers to ensure timely approvals or denials of requested services

Required Qualifications

• Active, unrestricted California nursing license as a Registered Nurse (RN) or Licensed Vocational/Practical Nurse (LVN/LPN); BSN preferred
• Minimum of 2-3 years of clinical nursing experience, including at least 1 year in utilization review or case management
• Strong knowledge of clinical guidelines (e.g., InterQual, MCG) and medical necessity criteria
• Preferred certifications include Certified Professional in Utilization Review (CPUR) or Certified Case Manager (CCM)
• Proficiency in electronic health records (EHR) and utilization management software