California Licensed Utilization Management RN

Job Summary

Working remotely, the California Licensed Utilization Management RN will manage the adverse determination processes, review medical records for service authorizations, and collaborate with pre-service and in-patient teams to ensure compliance and medical necessity in patient care.

Key responsibilities

• Review requests for referral authorizations and gather necessary information for determinations
• Ensure compliance with turnaround times and accuracy standards while coordinating with contracted providers
• Identify cases requiring additional case management and collaborate with internal departments to coordinate patient care

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 and HIPAA regulations