California Licensed Utilization Management Nurse

Job Summary

To promote quality and cost-effective outcomes, the full-time California Licensed Utilization Management Nurse will review prior authorization requests for medical services, collaborate with healthcare providers and patients, and ensure compliance with regulations while working remotely.

Key responsibilities

• Evaluate and process prior authorization requests based on clinical guidelines and medical necessity
• Serve as a liaison between healthcare providers, patients, and health plans to facilitate the authorization process
• Accurately document all authorization-related activities and ensure compliance with relevant regulations

Required qualifications

• Active California license as a Registered Nurse (RN)
• Minimum 2 years of clinical nursing experience, preferably in utilization management or prior authorizations
• Familiarity with insurance authorization processes and medical billing/coding (e.g., ICD-10, CPT codes)
• Strong analytical skills and proficiency in medical terminology
• Experience with EMR systems and prior authorization platforms