California Licensed Utilization Nurse

Job Summary

To support effective inpatient utilization management, the full-time California Licensed Utilization Nurse will review acute hospital admissions and prior authorization requests, ensuring compliance with medical necessity criteria, while working remotely within the Pacific or Mountain Time Zones.

Key responsibilities:

• Conduct clinical reviews to determine appropriate utilization of medical services based on established guidelines
• Authorize healthcare services and document reviews accurately in the care management system
• Collaborate with the Medical Management team to coordinate care and prepare cases for physician review

Required qualifications:

• Current unrestricted Registered Nurse (RN) license in state of residence
• 3+ years of clinical nursing experience in an acute care hospital or LTAC setting
• 1+ years of Utilization Management experience in a hospital or insurance setting
• Experience applying Medicare and/or Medicaid guidelines
• Proficiency in using care management systems and Microsoft Office applications