California Licensed Utilization Management Nurse

Job Summary

To support the Utilization Management team, the full-time temporary California Licensed Utilization Management Nurse will ensure prior authorization requests meet contractual requirements, perform concurrent and post-service reviews of acute inpatient care, and participate in Utilization Management Care Programs while working remotely in California.

Key responsibilities

• Ensure prior authorization requests are completed according to contractual requirements and evidence-based standards
• Perform concurrent or post-service reviews of acute inpatient care services using established criteria
• Participate in Utilization Management Care Programs

Required qualifications

• Current unrestricted license as a Registered Nurse issued by the State of California
• Bachelor's degree in Nursing preferred, or an Associate's degree with a minimum of five years of experience in a patient care setting, including one year in Utilization Management or Case Management
• Working knowledge of managed care, Medicare D-SNP, Medi-Cal programs, and related regulations
• Familiarity with Centers for Medicare & Medicaid Services (CMS) guidelines
• Knowledge of Utilization Management and clinical nursing principles