California Licensed Utilization Review Nurse

Job Summary

Seeking a California Licensed Utilization Review Nurse, this remote position will manage prior authorization and retrospective reviews of outpatient and inpatient services while ensuring compliance with medical necessity criteria across various health plans, requiring open availability for five shifts weekly between 8 AM and 8 PM PST.

Key responsibilities:

• Complete prior authorization and retrospective reviews for elective inpatient admissions, outpatient procedures, and durable medical equipment
• Refer cases to Medical Directors as needed and maintain knowledge of regulations and accreditation standards
• Comply with internal policies and perform additional duties as requested

Required qualifications:

• Active and unrestricted LVN license in California
• At least one year of outpatient Utilization Management experience
• Proficiency in Microsoft applications such as Word, Excel, and Outlook