California RN/LVN Utilization Management

Job Summary

Seeking a remote California RN/LVN Utilization Management professional, the full-time nurse will review prior authorization requests for medical necessity across inpatient and outpatient services, applying CMS guidelines and Milliman Care Guidelines to ensure timely and accurate determinations while collaborating with providers and medical directors.

Key responsibilities

• Review pre-certification requests for medical necessity and refer to medical directors as needed
• Utilize CMS and Milliman Care Guidelines to assist in referral determinations
• Maintain established turnaround time goals for referral processing

Required qualifications

• Active California RN or LVN license
• Minimum of 3 years nursing experience in a clinical setting
• At least 1 year of pre-service Utilization Management experience
• Experience with managed care (Medicaid and/or Medicare)
• Knowledge of ICD-10 and CPT coding