California Licensed Utilization Management Nurse

Job Summary

The full-time California Licensed Utilization Management Nurse will manage prior authorization requests for medical procedures, medications, and services remotely, ensuring compliance with clinical guidelines and collaborating with healthcare providers and patients to facilitate appropriate benefit coverage.

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, communicating authorization decisions and collaborating with Medical Directors
• Accurately document authorization-related activities and ensure compliance with regulations and guidelines

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 coding (e.g., ICD-10, CPT codes)
• Experience with EMR systems and prior authorization platforms
• Bachelor of Science in Nursing (BSN) preferred but not required