California Licensed Utilization Review Nurse

Job Summary

To ensure the medical necessity and appropriateness of healthcare services, the remote California Licensed Utilization Review Nurse will conduct real-time clinical reviews, assess inpatient admissions, and collaborate with healthcare providers and the Medical Director on complex cases.

Key Responsibilities

• Conduct timely reviews of inpatient and skilled nursing services to determine medical necessity based on clinical guidelines
• Collaborate with the Medical Director on complex cases and provide comprehensive clinical summaries
• Process authorization requests and communicate with healthcare providers to ensure compliance with health plan policies

Required Qualifications

• Registered Nurse (RN) with an active, unrestricted California nursing license; BSN preferred
• Minimum of 2-3 years of clinical nursing experience, with 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)
• Strong knowledge of clinical guidelines and proficiency in electronic health records (EHR) and utilization management software