The nurse reviews medical necessity cases for a defined panel of members, supporting prospective, retrospective, and concurrent utilization management decisions. This role focuses on care coordination, discharge planning, and communication across the care continuum to support quality and cost-effective outcomes for patients in managed care populations. Work is primarily office-based and computer-focused, with some travel required.
Key Responsibilities
- Conduct prospective, retrospective, and concurrent medical necessity reviews.
- Apply clinical criteria and health plan guidelines during case review.
- Collaborate with the Medical Director on adverse determination notices.
- Coordinate discharge planning and communicate needs to transition-of-care teams.
- Support care coordination across settings and help identify member needs and resources.
- Serve as a resource to non-clinical team members when needed.
- Meet productivity targets and follow quality management policies and procedures.
Required
- Active and 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
- Hourly pay range of $26.35 to $39.53 for California-based roles.
- Health, life, and disability benefits.
- 401(k) savings plan with match.
- Paid time off and paid holidays.