California Licensed Utilization Management Nurse

Job Summary

Providing clinically efficient inpatient utilization management, the full-time California Licensed Utilization Management Nurse will review acute hospital admissions and authorization requests remotely while ensuring compliance with medical necessity guidelines and coordinating high-quality care.

Key responsibilities:

• Maintains clinical expertise and conducts reviews for appropriate utilization of medical services based on established guidelines
• Documents clinical reviews and decisions accurately in the care management system, ensuring timely processing of authorizations
• Collaborates with the Medical Management team to identify members for care coordination and prepares clinical information for case reviews

Required qualifications:

• Current unrestricted Registered Nurse (RN) license in state of residence
• Ability to obtain a California RN license within 90 days of hire
• 3+ years of clinical nursing experience in an acute care hospital or LTAC setting
• 1+ years of Utilization Management experience in a hospital or insurance setting
• Experience with Medicare and/or Medicaid guidelines and Milliman (MCG) or InterQual guidelines