Utilization Review Nurse

TEKsystems•Bakersfield, CA

1d•$51 - $51•Onsite

About The Position

The Utilization Review Nurse is responsible for coordinating care and ensuring the medical necessity and appropriateness of services through effective communication, clinical review, and adherence to regulatory and organizational guidelines. This role works collaboratively with providers and internal departments to support timely, compliant, and high-quality patient care outcomes.

Requirements

Active, unrestricted Registered Nurse (RN) license (California)
Minimum of 2 years of clinical experience in acute care, public health, community health, or chronic disease management
Utilization Review
Outpatient Coding

Nice To Haves

Bachelor’s degree in Nursing, Health Administration, or a related healthcare field
Experience with Utilization Management (UM) principles and processes
Familiarity with MCG clinical guidelines and Medi-Cal coverage criteria
Experience in case management or care coordination
Knowledge of community resources for seniors and individuals with disabilities (Kern County preferred)
Valid California Driver’s License and proof of auto liability insurance (up to 10% travel required)
Bilingual (English/Spanish) preferred

Responsibilities

Serve as a primary point of contact for contracted providers and internal staff, ensuring clear and timely communication regarding care coordination, referrals, and organizational policies and procedures.
Collaborate with Member Services and Provider Relations to address quality of care concerns and grievance cases, facilitating timely and effective resolution.
Review and process referrals for Durable Medical Equipment (DME), home health, and outpatient services, applying clinical guidelines and Medi-Cal criteria to determine medical necessity and benefit coverage.
Identify and escalate cases involving quality of care issues, coordination of benefits, and third-party liability as appropriate.
Maintain comprehensive knowledge of covered benefits across all programs to ensure accurate determination and processing of requests.
Assess cases for referral to internal programs, including Case Management, Transitions of Care, Major Organ Transplant, and Community Support Services (e.g., Enhanced Care Management).
Identify authorization-related issues and escalate concerns requiring review to the UM Outpatient Clinical Supervisor.
Evaluate requests for non-par provider services and coordinate review with the Medical Director based on provider availability within the member’s geographic area.
Prepare and process member and provider correspondence, including denial letters, ensuring accuracy, compliance, and timely distribution.
Determine medical appropriateness and necessity of care in accordance with established criteria and mandated turnaround times.
Refer cases that do not meet medical necessity criteria to the Medical Director for further review.
Maintain up-to-date knowledge of California Children’s Services (CCS) guidelines to support coordination of services.
Perform additional duties as assigned to support departmental goals and operational needs.