Registered Nurse- Utilization Management

HJ Staffing • Long Beach, CA

2d

About The Position

We are seeking a Registered Nurse (RN) to join the Utilization Management team. The role performs concurrent reviews, prior authorizations, medical necessity reviews, discharge planning, and transitions of care. The RN collaborates with physicians, hospitals, and interdisciplinary teams to help ensure members receive appropriate, cost-effective, evidence-based care. The position is suited to an RN with a strong acute care background and experience in managed care and utilization management.

Requirements

• Active Registered Nurse (RN) license, with 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 is required.
• Direct experience with concurrent review and inpatient utilization management.
• Direct experience with discharge planning and transitions of care.
• Experience using InterQual, MCG, and CMS guidelines.
• Proficiency with medical management software and Microsoft Office Suite.
• Strong critical-thinking, communication, and organizational skills.

Nice To Haves

• Bachelor of Science in Nursing (BSN).
• Clinical background in an 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 making accurate medical necessity determinations.
• Ability to navigate challenging conversations regarding levels of care.
• Ability to manage multiple dynamic cases in a fast-paced managed care environment.
• Detail-oriented approach 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 transitions of care with providers and healthcare facilities.
• Collaborate with physicians, hospital staff, specialists, and internal care management teams.
• Request and review additional clinical documentation as needed, and escalate complex medical necessity cases to the Medical Director.
• Educate providers on utilization management policies and review criteria.
• Document reviews and decisions in medical management systems.
• Identify care gaps and support quality improvement initiatives.

What This Job Offers

• Job Type: Full-time
• Education Level: No Education Listed