California Licensed Utilization Management RN

Job Summary

Working remotely, the California Licensed Utilization Management RN will manage the integrity of adverse determination processes, review medical records, and authorize requested services while ensuring compliance and fiscal responsibility.

Key responsibilities

• Review designated requests for referral authorizations and gather necessary information for determinations
• Ensure compliance with turnaround times and accuracy standards in utilization management decisions
• Coordinate with internal departments and staff to facilitate optimal patient care and identify cases requiring additional management

Required qualifications

• Three (3) years of recent clinical experience
• Graduate of an accredited RN program
• Clear and current California Registered Nurse (RN) license
• Knowledge of ICD-10, CPT, HCPCS coding, medical terminology, and insurance benefits
• Understanding of legal and ethical considerations related to patient information, PHI, and HIPAA regulations