California Licensed Utilization Management RN

Job Summary

Working remotely, the full-time California Licensed Utilization Management RN will manage the efficient use of healthcare resources, conduct utilization reviews, and collaborate with healthcare teams to ensure quality patient care and compliance with guidelines.

Key responsibilities

• Coordinate with healthcare professionals to assess and monitor the delivery of appropriate levels of care
• Conduct comprehensive medical records reviews to evaluate medical necessity and adherence to guidelines
• Manage denials and appeals by preparing cases and collaborating with physician advisors for evidence-based recommendations

Required qualifications

• Bachelor's Degree in Nursing from an accredited college or university
• Three years of progressively responsible experience in utilization management or related healthcare roles
• California RN state licensure or compact state licensure required
• Accredited Case Manager Certification (ACM) or Case Management Certification (CCM) preferred
• Solid understanding of utilization management principles and transitions of care guidelines