California Licensed Utilization Management RN

Job Summary

Serving as a subject matter expert in prior authorization and letter review processes, the remote Team Lead - UM Regulatory & Compliance, RN will manage daily operations of clinical staff, ensure adherence to regulatory standards, and collaborate with leadership to drive quality initiatives in a full-time capacity.

Key responsibilities

• Oversee daily operations of the Utilization Management team and ensure compliance with regulatory standards
• Act as a first-line resource for clinical staff, providing guidance on UM processes and addressing issues as they arise
• Collaborate with leadership to implement LEAN project initiatives and monitor UM metrics for continuous improvement

Required qualifications

• Associate's degree in nursing from an accredited institution; Bachelor's degree preferred
• A minimum of three years of experience in clinical utilization management processes
• At least two years of direct clinical patient care experience in an acute care facility with an active RN license
• Advanced knowledge of UM policies, regulations, and nationally recognized criteria
• Bilingual (English/IEHP Threshold Language) skills preferred