Utilization Review Nurse

Utilization Review Nurse

• This is a full-time, onsite role in El Monte, CA. No Hybrid No Remote

Schedule : 35-hour work week

Hours : 8 : 30am-4 : 30pm with an hour lunch

Annual Salary : $125,000

About the Role

The Utilization Management team performs prospective, concurrent, and retrospective utilization reviews using evidenced based guidelines. The Utilization Management Nurse reports to the Director of Utilization Management. This role conducts clinical review of authorization requests at various levels of care for medical necessity, coding accuracy, and medical policy compliance. Conduct pre and post service review of inpatient admissions, outpatient services, special procedures and home care to assess the medical necessity and appropriateness of services.

Job Description

Perform prospective, concurrent, and retrospective utilization reviews for members using evidenced based guidelines, policies and nationally recognized clinal criteria. Document rationale for nursing decision making.

Gather clinical information and apply the appropriate clinical criteria / guideline, policy, procedure and clinical judgment to render coverage determination / recommendation along the continuum of care facilitates including effective discharge planning at levels of care appropriate for the members needs and acuity; prepare and present cases to Medical Director (MD) for medical director oversight, necessity determination, and adverse determinations.

Conduct clinical review of workers compensation cases and claims in support of third-party liability and presumptive diagnosis.

Coordinate patient care services optimizing member benefits to promote appropriate, safe and effective care to members and effective utilization of Plan resources. Discuss cases with attending physicians, healthcare professionals, para-professional support staff and patients. Support team through consistent and successful caseload management and workload to achieve team goals, regulatory timelines, and accreditation standards

Your Knowledge and Experience

Current unrestricted CA Registered Nurse (RN) or Licensed Vocational Nurse (LVN / LPN) license required

Requires at least three (3) years of prior experience in healthcare related field

Verifiable Utilization Management experience for a health insurance plan required

Strong understanding of Utilization Management including ability to apply and interpret admission and continued stay criteria of multiple standardized clinical criteria sets including but not limited to MCG guidelines and various Medicare guidelines

Familiarity with medical terminology, diagnostic terms, and treatment modalities including ability to comprehend psychiatric evaluations, clinical notes, and lab results

Proficient with Microsoft Excel, Outlook, Word, Power Point, and the ability to learn and utilize multiple systems / databases

Excellent analytical, communication skills, written skills, time management, and organizational skills

Possess outstanding interpersonal, organizational, and communication skills, positive attitude, and high level of initiative

Ability to identify problems and works towards problem resolution independently, seeking guidance as needed

Work Environment

Onsite position only – remote work is not available

Collaborative, mission-driven team focused on member care and regulatory excellence

Compensation & Benefits

Competitive salary commensurate with experience

100% employer-paid health coverage for employee and eligible dependents starting on Day One

Generous retirement plan with 7% employer contribution

Paid holidays, vacation, and professional development opportunities