The clinician primarily performs utilization management reviews for a defined panel of members, applying medical necessity criteria and coordinating care decisions across settings. This role supports patient-centered care across the continuum, including discharge planning and communication with transition-of-care teams when needed. It is a part-time position with weekend availability required, and most work is desk-based with some travel possible.
Key Responsibilities
- Perform prospective, retrospective, or concurrent medical necessity reviews for assigned members.
- Apply clinical criteria such as Medicare, Medicaid/Medi-Cal, InterQual, Milliman, and health plan-specific guidelines.
- Collaborate with the Medical Director on adverse determination notices and documentation quality.
- Coordinate timely discharge planning and communicate needs to transition-of-care teams.
- Meet productivity targets and support efficient review workflows.
- Serve as a resource to non-clinical team members when appropriate.
- Follow Quality Management Committee policies and procedures.
Required
- Active, unrestricted California LVN license.
- Minimum 2 years of experience in medical management clinical functions.
- Working knowledge of MCG, InterQual, and NCQA standards.
Preferred
- Associate’s degree in Nursing.
- Managed Care Nursing (CMCN) certification.
Benefits & Perks
- Part-time schedule with weekend availability.
- Health, life, and disability benefits.
- 401(k) savings plan with match.
- Paid time off and paid holidays.
- Some travel may be required.
- Compensation range of $26.35-$39.53 hourly.