Registered Nurse – Utilization Review - RNUR 26-06574

NavitasPartners•Apple Valley, CA

1d•Onsite

About The Position

We are seeking an experienced Utilization Review Registered Nurse (RN) to support care management and utilization review functions within an acute care hospital setting. The ideal candidate will have extensive experience performing utilization review, medical necessity assessments, and care coordination while ensuring compliance with regulatory requirements, payer guidelines, and organizational standards.

Requirements

Associate Degree in Nursing (ADN) required.
Active California Registered Nurse (RN) License required.
Pending California RN License accepted; license must be active prior to assignment start date.
Minimum three (3) years of recent acute care hospital Utilization Review and/or Care Management experience required.
Experience performing utilization review within a hospital setting required.
Experience with medical necessity reviews, level-of-care determinations, and payer authorization processes required.
Health plan, insurance, or medical group-only experience will not be considered.
Previous travel assignment experience required.
Strong knowledge of utilization review principles and regulatory requirements.
Experience applying clinical criteria and medical necessity guidelines.
Ability to analyze complex clinical documentation and make appropriate level-of-care recommendations.
Knowledge of discharge planning and care coordination processes.
Excellent communication and interdisciplinary collaboration skills.
Strong organizational and time-management abilities.
Ability to manage a high-volume patient caseload effectively.
Strong critical-thinking, problem-solving, and decision-making skills.
Proficiency with electronic medical records and utilization management systems.
Commitment to quality outcomes, regulatory compliance, and patient-centered care.

Nice To Haves

Bachelor of Science in Nursing (BSN) preferred.
Seasoned traveler experience strongly preferred.

Responsibilities

Perform utilization review and medical necessity assessments for inpatient admissions and continued stays.
Evaluate clinical documentation to determine appropriate level of care and resource utilization.
Apply evidence-based criteria and payer guidelines to support utilization management decisions.
Collaborate with physicians, case managers, and interdisciplinary healthcare teams to facilitate appropriate patient care.
Monitor patient progression through the continuum of care and identify barriers to discharge.
Communicate with payers and healthcare providers regarding authorization requirements and coverage determinations.
Ensure compliance with federal, state, accreditation, and organizational utilization management standards.
Maintain accurate and timely documentation of utilization review activities.
Participate in denial prevention and appeals processes when applicable.
Support quality improvement initiatives related to care management and utilization review.
Assist with discharge planning and care coordination activities as needed.
Promote efficient resource utilization while maintaining high-quality patient care outcomes.