Registered Nurse - Utilization Management

myPlace Health•Los Angeles, CA

9d•$53 - $58

About The Position

myPlace Health is built around a simple but powerful belief: older adults deserve the support they need to live safely, independently, and with dignity in their own communities. As a PACE (Program of All Inclusive Care for the Elderly) organization backed by SCAN Group, myPlace Health brings together customized medical care, social activities, and daily support for participants and their families – all under one roof. Our centers are more than healthcare facilities. They are vibrant community hubs where participants are known by name, valued, and supported as whole people. Behind that experience is a dedicated, interdisciplinary team working together to coordinate care, remove barriers, and improve quality of life for some of the most medically and socially complex populations. For employees, myPlace Health offers the opportunity to do deeply meaningful work in a highly collaborative setting. Team members are encouraged to contribute innovative ideas, and grow alongside a mission that prioritizes compassion, respect, and impact. The result is a culture where people feel connected—to their colleagues, their participants, and the communities they serve. At myPlace Health, work is more than a job. It’s a shared commitment to honoring what matters most. The Utilization Management Nurse supports the delivery of high-quality, medically necessary, cost-effective, and compliant care for myPlace Health participants. This role reviews, coordinates, and monitors participant services to ensure care decisions align with clinical needs, PACE requirements, and applicable Medicare and Medicaid guidelines. Working within the Health Plan Department, the Utilization Management Nurse partners with the Interdisciplinary Team, providers, contracted facilities, and internal stakeholders to support authorization processes, care coordination, utilization review, and documentation accuracy. This position also contributes to the development of utilization management workflows and process improvements that promote operational efficiency, compliance, and participant-centered care.

Requirements

Active, unrestricted RN license in the state of practice.
Minimum of three (3) years of nursing experience, preferably in geriatrics, acute care, case management, utilization management, or a related clinical setting.
Strong understanding of Medicare/Medicaid coverage criteria, managed care principles, medical necessity review, and applicable PACE program requirements.
Demonstrated passion and mission alignment for serving high-risk seniors, frail older adults, and medically complex populations.
Strong critical thinking, clinical judgment, problem-solving, and decision-making skills.
Ability to work effectively in a collaborative, participant-centered environment while maintaining regulatory, compliance, and documentation standards.
Exceptional communication and interpersonal skills, with the ability to coordinate across providers, facilities, vendors, participants, caregivers, and internal teams.
Proficiency with electronic medical record systems, utilization management platforms, and related digital workflows.
Ability to work independently, manage multiple priorities, and appropriately escalate issues with minimal supervision.
Experience working in a health plan, PACE organization, managed care environment, or value-based care model.

Nice To Haves

CCM, CPUR, CPHM, or other relevant case management or utilization review certification.

Responsibilities

Review, process, and document requests for services, referrals, equipment, and other participant care needs based on medical necessity criteria, Medicare/Medicaid guidelines, and PACE requirements.
Conduct concurrent and retrospective utilization reviews for inpatient, outpatient, specialty care, skilled nursing facility, and ancillary services.
Monitor hospitalizations, skilled nursing facility stays, and transitions of care to support safe, timely, and appropriate discharge planning.
Collaborate with the Interdisciplinary Team to ensure utilization management decisions align with individualized participant care plans, clinical needs, and participant-centered goals.
Communicate utilization management decisions to providers, participants, caregivers, and internal team members in accordance with regulatory and organizational timeframes.
Serve as a liaison with contracted providers, hospitals, skilled nursing facilities, and ancillary vendors to support efficient, coordinated, and participant-centered care delivery.
Identify service requests requiring physician or Medical Director review and escalate appropriately for clinical determination.
Maintain accurate, timely, and audit-ready documentation of utilization management activities in the electronic medical record and health plan systems.
Support compliance with CMS, DHCS, Medicare, Medicaid, and PACE requirements, including participation in audits, quality assurance activities, compliance reviews, and process improvement efforts.
Contribute to the development, refinement, and implementation of utilization management policies, procedures, workflows, documentation standards, and staff/provider education.
We seek Rebels who are curious about AI and its power to transform how we operate and serve our members.
All other duties as assigned.