Utilization Management

HJ Staffing • Long Beach, CA

1d

About The Position

We are seeking a Registered Nurse (RN) to join our Utilization Management team. In this role, you will perform concurrent reviews, prior authorizations, medical necessity reviews, discharge planning, and transitions of care. You will collaborate closely with physicians, hospitals, and interdisciplinary teams to ensure members receive appropriate, cost-effective, and evidence-based care. This position is ideal for an RN with a strong acute care background and proven experience in managed care and utilization management.

Requirements

• Active Registered Nurse (RN) license (ability to obtain multi-state licensure if needed).
• Graduate of an accredited School of Nursing.
• Minimum 4 years of clinical nursing experience.
• Minimum 2 years of managed care or HMO experience (Medicare Advantage experience required).
• Direct experience in Concurrent Review & Inpatient Utilization Management.
• Direct experience in Discharge Planning & Transitions of Care.
• Direct experience Utilizing InterQual, MCG, and CMS Guidelines.
• Proficiency with medical management software and Microsoft Office Suite.
• Strong critical thinking, excellent communication, and exceptional organizational skills.

Nice To Haves

• Bachelor of Science in Nursing (BSN).
• Clinical background in Emergency Department (ER) or Intensive Care Unit (ICU).
• Case Management experience.
• Prior Utilization Management experience directly within a health plan or managed care organization.
• Experience working directly with hospitals, physicians, and provider networks.
• Strong clinical judgment and confidence in making accurate medical necessity determinations.
• Ability to comfortably navigate challenging conversations regarding levels of care.
• High organizational skills to manage multiple dynamic cases simultaneously in a fast-paced managed care environment.
• A detail-oriented mindset committed to high-quality patient outcomes.

Responsibilities

• Perform concurrent, prior authorization, and retrospective utilization reviews.
• Evaluate medical necessity using InterQual, MCG, CMS, and LCD/NCD guidelines.
• Coordinate discharge planning and seamless transitions of care with providers and healthcare facilities.
• Work alongside physicians, hospital staff, specialists, and internal care management teams.
• Request and review additional clinical documentation as needed; escalate complex medical necessity cases to the Medical Director.
• Educate providers on utilization management policies and review criteria.
• Accurately document all reviews and decisions within medical management systems while identifying care gaps and supporting quality improvement initiatives.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Associate degree