California State Licensed Utilization Management Nurse

Job Summary

A company is looking for a Utilization Management Nurse (LVN) for a remote administrative position.

Key Responsibilities:

• Performing daily clinical reviews while patients are in the hospital/SNF
• Transferring members to an in-network hospital from an out-of-network ER/hospital

Required Qualifications:

• Clear and active LVN CA State license
• 2+ years of telephonic utilization review/management experience from an acute care/inpatient/hospital stay setting (not payor side)
• Experience with an MSO, Health Plan, or Delegated Risk arrangement
• Understanding of regulatory requirements such as Medicare, Medi-Cal, and Commercial/DMHC
• Computer savvy with Microsoft Office, strong skills in Excel; experience using Milliman or Interqual, EZ Cap 6 is a plus