Utilization Management Nurse (CA)

Job Summary
The Utilization Management (UM) Nurse is responsible for conducting clinical reviews and evaluating the medical necessity, appropriateness, and efficiency of healthcare services requested by providers and members. This role supports the health plan's utilization management processes in accordance with established clinical guidelines, plan benefits, regulatory requirements, and accreditation standards. The UM Nurse plays a critical role in ensuring the delivery of cost-effective and quality healthcare services to members.

Essential Functions/Key Responsibilities:

• Performs timely and accurate utilization review of inpatient, outpatient, and ancillary services using standardized clinical criteria (e.g., MCG, InterQual).
• Reviews prior authorization requests and determines medical necessity based on clinical documentation, benefit guidelines, and regulatory standards.
• Documents clinical decisions, rationale, and communication with providers and members in the designated UM system.
• Collaborates with departments including Case Management, Disease Management, Pharmacy, and Provider Relations to support care coordination and continuity of care.
• Refers complex or non-standard cases to physician reviewers or interdisciplinary care teams as appropriate.
• Participates in denial and appeal processes, including preparing clinical summaries and supporting documentation for medical director review.
• Maintains current knowledge of regulatory and accreditation requirements (e.g., CMS, NCQA, state mandates) affecting utilization management.
• Assists with audits, quality improvement initiatives, and accreditation preparation related to UM activities.
• May participate in inter-rater reliability testing, clinical guideline updates, and policy review.
• Receives inbound or places outbound calls relating to the member’s individual needs.
• Performs prospective, concurrent, post-service and retrospective claims medical review processes. Utilizing considerable clinical judgement, independent analysis, critical-thinking skills and detailed knowledge of medical policies, clinical guidelines and benefit plans to complete reviews and determinations within required turnaround times specific to the case type. Identifies cases needing Physician Advisor (PA) review or input. Presents cases to PA for potential review or determinations when needed.
• Performs telephonic admission and concurrent review, and collaborates with on-site facility staff, physicians, providers, the member and significant others to develop and implement a successful discharge plan, if contracted by client.
• Generate appropriate member and provider communication for all determinations within the required timelines as defined by the most current department policy.
• Support Toney business need by floating to different clients and cross training as needed.
• Provide updates to Manager of Utilization Management

Competencies:

• Excellent written and verbal communication skills with strong attention to detail.
• Highly organized and proactive, with the ability to manage multiple priorities at once.
• Proficient in Microsoft office suite.
• Ability to thrive in a fast-paced, evolving healthcare environment.

Required education and experience:

• Education Required: Associate degree in Nursing
• Active, unrestricted Registered Nurse (RN) license in the applicable state or compact license. State of California is highly desirable.
• Minimum 3 years of prior experience in Health Insurance Company Utilization Management
• Strong understanding of using MCG and/or InterQual and/or CMS Criteria
• Working knowledge of UM-related regulatory and accreditation standards, including CMS, NCQA, and URAC.
• Strong clinical judgment, critical thinking, and communication skills.
• Familiarity with electronic medical records and utilization management platforms.

Preferred

• Education Preferred: Bachelor’s degree in Nursing
• Certification in Case Management (CCM) or Utilization Review (e.g., CPUR, CPUM).
• Experience using UM systems such as TruCare, GuidingCare, Jiva, or similar platforms.
• Previous experience in appeals and grievances, concurrent review, or behavioral health UM is a plus.
• Multistate Compact Nursing License (RN)

Physical Requirements/Work environment:

• Remote with periodic travel as required <10%.
• Must have a home office, mobile phone, and computer with security requirements met.
• Prolonged periods of sitting at a desk and working on a computer.
• Ability to speak, hear, and comprehend both written and verbal communications.

Job Type: Full-time, Contract

Schedule:

• Monday to Friday
• 8-hour shift, 8am-5pm Pacific time

Work Location: Remote

Other duties:

This job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities, and/or activities may change at any time with or without advanced notice.

Pay: $89,228.53 - $107,458.02 per year

Experience:

• Health Insurance Company Utilization Management : 3 years (Required)
• Utilization Managment: 3 years (Required)

License/Certification:

• RN License (Required)
• California RN licensure (Required)

Work Location: Remote