California Licensed Utilization Review RN

Job Summary

Leading a team of clinical reviewers, the full-time California Licensed Utilization Review RN will provide operational leadership in a remote setting, ensuring timely and evidence-based coverage determinations while coaching staff and promoting compliance with regulatory standards.

Key responsibilities

• Oversee daily operations of the Utilization Management team, setting priorities and promoting a culture of clinical quality
• Coach and develop reviewers on medical-necessity criteria and documentation standards, providing real-time guidance and support
• Collaborate with internal and external stakeholders to resolve barriers and ensure smooth transitions in care

Required qualifications

• California RN Licensure required; prior supervisory experience in utilization review preferred
• 5+ years of combined clinical experience, with over 2 years specifically in utilization review
• Knowledge of medical claims and coding (ICD-10, CPT, HCPCS)
• Strong proficiency in Microsoft Office applications
• Ability to evaluate claims data critically and determine appropriate treatment plans