California Licensed Utilization Management RN

Job Summary

To support effective healthcare delivery, the part-time California Licensed Utilization Management RN will manage utilization reviews, coordinate care with healthcare teams, and ensure compliance with regulatory standards while working remotely.

Key responsibilities

• Conduct comprehensive utilization reviews on patient medical records to determine medical necessity and appropriate levels of care
• Collaborate with healthcare professionals and payers to optimize patient care and resource utilization
• Manage denials and appeals by reviewing cases and preparing persuasive appeals in conjunction with physician advisors

Required qualifications

• Bachelor's Degree from an accredited college or university required; Master's Degree preferred
• Three (3) years of progressively responsible experience in case management or utilization review
• CA-RN (Registered Nurse) license required
• Certified Case Manager (CCM) or equivalent certification required
• Basic knowledge of applicable laws and regulations related to healthcare and insurance