California Licensed Utilization Nurse

Job Summary

To promote quality and cost-effective outcomes, the full-time California Licensed Utilization Nurse will manage prior authorization requests, collaborate with healthcare providers and patients, and ensure compliance with regulatory requirements while working remotely.

Key responsibilities

• Evaluate and process prior authorization requests based on clinical guidelines and medical necessity
• Act as a liaison between healthcare providers, patients, and health plans to facilitate the authorization process
• Accurately document all authorization activities and maintain compliance with federal, state, and health plan regulations

Required qualifications

• Active, unrestricted California nursing license as a Licensed Vocational/Practical Nurse (LVN/LPN)
• Minimum of 2-3 years of clinical nursing experience, including at least 1 year in utilization review or case management
• Experience in a managed care setting with medical necessity reviews is strongly preferred
• Preferred certifications include Certified Professional in Utilization Review (CPUR) or Certified Case Manager (CCM)
• Proficiency in medical terminology and experience with EMR systems and prior authorization platforms