This role focuses on concurrent utilization review for inpatient, skilled nursing, and post-acute services, with a clinical emphasis on medical necessity, level-of-care decisions, and continued stay reviews. The nurse communicates with providers and payers, supports authorization decisions, and helps coordinate discharge planning and care transitions. It is a collaborative utilization management role that uses clinical guidelines and documentation review in a managed care setting, with remote work potentially considered.
Key Responsibilities
- Conduct concurrent reviews of inpatient, skilled nursing, LTAC, and inpatient rehab services for medical necessity and appropriateness.
- Evaluate clinical documentation to support level-of-care determinations, treatment plans, continued stays, and discharge readiness.
- Coordinate with providers, case managers, social workers, and care teams to support care transitions and discharge planning.
- Process authorization requests and communicate approvals, denials, and documentation needs to providers and payers.
- Escalate complex or borderline cases to the Medical Director and provide clinical summaries for review.
- Maintain accurate documentation of reviews, authorizations, denials, escalations, and director-level decisions.
- Apply health plan policies, clinical guidelines, and regulatory standards in daily utilization review work.
- Participate in interdisciplinary discussions, case conferences, and quality improvement efforts.
Required
- Active, unrestricted California RN or LVN/LPN license.
- 2-3 years of clinical nursing experience.
- At least 1 year of experience in utilization review, case management, or a related field.
- Strong knowledge of medical necessity criteria and clinical review guidelines.
Preferred
- BSN.
- Experience in a managed care setting.
- Certification such as CPUR, CCM, or ACM.
- Experience using EHR systems, utilization management software, and Microsoft Office.
Benefits & Perks
- Remote work may be considered.
- Health benefits, life and disability benefits.
- 401(k) savings plan with match.
- Paid time off and paid holidays.
- Hourly compensation range of $26.35-$39.53 for California-based employees.