California Licensed Utilization Review Nurse

Job Summary

A company is looking for a Utilization Review Nurse to ensure high-quality care for health plan members.

Key Responsibilities

• Conduct utilization management activities in line with health plan policies and regulations
• Identify and report Potential Quality Issues and support Provider Dispute Resolution processes
• Complete additional duties as assigned

Required Qualifications

• BSN or MSN degree
• Current valid California RN license
• Two or more years of experience in utilization management, preferably in Medicare Advantage or managed care
• Knowledge of Medicare Advantage regulatory guidelines and CMS regulations
• Experience with Potential Quality Issues identification and reporting