California Licensed Utilization Management Nurse

Job Summary

Working remotely in a full-time capacity, the California Licensed Utilization Management Nurse will manage authorization processes, conduct utilization reviews for hospital admissions and outpatient services, and collaborate with healthcare providers to ensure patient-centered care.

Key responsibilities

• Interface with external agencies regarding the utilization management process, including health plans and medical providers
• Perform utilization review activities for elective and urgent hospital admissions, ensuring timely reporting to stakeholders
• Assist medical directors with benefit interpretation and provide case discussions as needed

Required qualifications

• California RN licensure required
• 2 years of recent relevant experience in utilization management or a related field
• Experience with MCG or InterQual guidelines highly desired
• Familiarity with healthcare reimbursement systems and coding (ICD-9, CPT, HCPCS) preferred
• Prior experience in a Managed Services Organization (MSO) is preferred