The nurse conducts concurrent utilization reviews for inpatient, skilled nursing, and post-acute services to determine medical necessity, level of care, and continued stay appropriateness for managed care members. The role includes authorizing admissions, reviewing documentation against clinical guidelines, and supporting discharge planning and care transitions. It also involves frequent coordination with providers, case managers, and the Medical Director on complex or escalated cases.
Key Responsibilities
- Conduct real-time reviews of inpatient and skilled nursing services using medical necessity criteria and clinical guidelines.
- Evaluate clinical documentation to support admission decisions, continued stays, level-of-care determinations, and treatment plans.
- Process authorization requests for inpatient, LTAC, inpatient rehab, and skilled nursing admissions.
- Communicate with providers to request additional information, clarify treatment plans, and resolve utilization review questions.
- Coordinate with case managers, social workers, and care teams to support discharge planning and care transitions.
- Escalate complex, borderline, or denied cases to the Medical Director for review.
- Maintain accurate documentation of reviews, authorizations, denials, escalations, and clinical decisions.
- Participate in interdisciplinary meetings and support quality improvement efforts related to utilization trends.
Required
- Active, unrestricted California RN or LVN/LPN license.
- At least 4 years of clinical nursing experience.
- At least 1 year of experience in utilization review, case management, or a related field.
- Experience with medical necessity reviews in a managed care setting.
- Strong knowledge of clinical guidelines and utilization management criteria.
- Proficiency with EHR systems, utilization management software, and Microsoft Office.
Preferred
- BSN.
- CPUR, CCM, or ACM certification.
- Experience with InterQual or MCG guidelines.
- Prior experience in a managed care environment.
Benefits & Perks
- Remote work may be considered.
- Collaborative environment with frequent interaction across clinical and administrative teams.
- Opportunity to work in a value-driven, coordinated care model.