About This Position
Remote Utilization Management Preservice Nurse-Denial Letter Dept. (RN or LVN – California License Required)
Contract-to-Permanent Hire | Fully Remote (U.S.)
May reside anywhere in the US as long as you have an active California RN or LNV license. (CA is NOT a compact state)
A rapidly growing healthcare services organization is seeking a Utilization Management Nurse (RN or LVN) to support pre-service and prior authorization reviews. We are looking for Nurses that have Preservice Review experience along with robust Denial Letter writing experience using clinical rational - not just templates. This role plays a key part in ensuring patients receive appropriate, timely, and cost-effective care while working collaboratively with physicians, care teams, and healthcare providers.
This is a 100% remote opportunity open to candidates anywhere in the United States, however an active California RN or LVN license is required.
This position begins as a contract role with strong potential for permanent hire based on performance.
Schedule:
Monday - Friday or Tuesday - Saturday | 8:00 AM – 5:00 PM PST (Preservice Team)
Sunday - Thursday | 8:00 AM – 5:00 PM PST (Preservice/Denials Team)
Key Responsibilities
Review prior authorization and pre-service requests for inpatient and outpatient care.
Develop and issue custom denial letters that clearly articulate clinical rationale, using member-specific documentation and evidence-based criteria (e.g., MCG, InterQual, CMS guidelines).
Ensure denial determinations are well-supported, compliant, and audit-ready, avoiding reliance on templated language.
Analyze clinical records and documentation to support accurate, defensible coverage decisions.
Evaluate medical necessity using clinical guidelines such as MCG, InterQual, or comparable evidence-based criteria.
Collaborate with physicians, providers, case managers, and medical directors to support care determinations.
Verify patient eligibility, benefits, and accuracy of medical coding (ICD-10, CPT).
Ensure requests are processed within required turnaround times while maintaining accurate documentation.
Provide clinical input for appeals and grievance reviews when necessary.
Communicate professionally with providers, patients, and internal teams regarding care decisions.
Assist with single-case agreements or out-of-network service reviews when applicable.
Participate in team meetings, case discussions, and quality improvement initiatives.
Required Qualifications
Active, unrestricted California RN or LVN license
Minimum 1 year of Medicare experience
Experience or familiarity with utilization management, prior authorization, or clinical review
Understanding of medical terminology, coding (ICD-10/CPT), and CMS guidelines
Strong critical thinking and clinical decision-making skills
Excellent written and verbal communication
Ability to manage multiple requests and meet deadlines in a fast-paced environment
Proficiency with Microsoft Office (Word, Excel, Outlook)
Preferred Qualifications
2+ years of experience in utilization management, managed care, or hospital settings
Experience using MCG (Milliman), InterQual, or similar clinical guidelines
Familiarity with Medicare Managed Care Plans
Compensation & Benefits
Contract-to-Permanent Hire Opportunity
100% Remote Work Environment
Medical, dental, and vision insurance
401(k) with employer contributions
Professional development and training opportunities
Apply today if you're a licensed California RN or LVN looking for a remote role in utilization management with long-term career potential.
Equal Opportunity Employer
We are an Equal Opportunity Employer and are committed to fostering a diverse and inclusive workplace. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, gender identity, sexual orientation, pregnancy, national origin, age, disability, genetic information, veteran status, or any other characteristic protected by applicable federal, state, or local laws.
Job Type: Full-time
Pay: $100,000.00 - $105,000.00 per year
Benefits:
401(k)
401(k) matching
Dental insurance
Disability insurance
Employee assistance program
Employee discount
Flexible schedule
Flexible spending account
Health insurance
Health savings account
Life insurance
Paid time off
Parental leave
Professional development assistance
Referral program
Retirement plan
Travel reimbursement
Vision insurance
Application Question(s):
Have you worked for a health plan that services Medicare members?
Do you have experience independently writing denial letters using clinical rationale (not relying solely on templates)?
Experience:
Preservice/Prior Authorization: 1 year (Required)
Medicare Advantage : 1 year (Required)
CMS Guidelines: 1 year (Required)
Language:
Fluent Spanish (Preferred)
License/Certification:
CALIFORNIA RN/LVN License (CA is not compact) (Required)
Work Location: Remote
Contract-to-Permanent Hire | Fully Remote (U.S.)
May reside anywhere in the US as long as you have an active California RN or LNV license. (CA is NOT a compact state)
A rapidly growing healthcare services organization is seeking a Utilization Management Nurse (RN or LVN) to support pre-service and prior authorization reviews. We are looking for Nurses that have Preservice Review experience along with robust Denial Letter writing experience using clinical rational - not just templates. This role plays a key part in ensuring patients receive appropriate, timely, and cost-effective care while working collaboratively with physicians, care teams, and healthcare providers.
This is a 100% remote opportunity open to candidates anywhere in the United States, however an active California RN or LVN license is required.
This position begins as a contract role with strong potential for permanent hire based on performance.
Schedule:
Monday - Friday or Tuesday - Saturday | 8:00 AM – 5:00 PM PST (Preservice Team)
Sunday - Thursday | 8:00 AM – 5:00 PM PST (Preservice/Denials Team)
Key Responsibilities
Review prior authorization and pre-service requests for inpatient and outpatient care.
Develop and issue custom denial letters that clearly articulate clinical rationale, using member-specific documentation and evidence-based criteria (e.g., MCG, InterQual, CMS guidelines).
Ensure denial determinations are well-supported, compliant, and audit-ready, avoiding reliance on templated language.
Analyze clinical records and documentation to support accurate, defensible coverage decisions.
Evaluate medical necessity using clinical guidelines such as MCG, InterQual, or comparable evidence-based criteria.
Collaborate with physicians, providers, case managers, and medical directors to support care determinations.
Verify patient eligibility, benefits, and accuracy of medical coding (ICD-10, CPT).
Ensure requests are processed within required turnaround times while maintaining accurate documentation.
Provide clinical input for appeals and grievance reviews when necessary.
Communicate professionally with providers, patients, and internal teams regarding care decisions.
Assist with single-case agreements or out-of-network service reviews when applicable.
Participate in team meetings, case discussions, and quality improvement initiatives.
Required Qualifications
Active, unrestricted California RN or LVN license
Minimum 1 year of Medicare experience
Experience or familiarity with utilization management, prior authorization, or clinical review
Understanding of medical terminology, coding (ICD-10/CPT), and CMS guidelines
Strong critical thinking and clinical decision-making skills
Excellent written and verbal communication
Ability to manage multiple requests and meet deadlines in a fast-paced environment
Proficiency with Microsoft Office (Word, Excel, Outlook)
Preferred Qualifications
2+ years of experience in utilization management, managed care, or hospital settings
Experience using MCG (Milliman), InterQual, or similar clinical guidelines
Familiarity with Medicare Managed Care Plans
Compensation & Benefits
Contract-to-Permanent Hire Opportunity
100% Remote Work Environment
Medical, dental, and vision insurance
401(k) with employer contributions
Professional development and training opportunities
Apply today if you're a licensed California RN or LVN looking for a remote role in utilization management with long-term career potential.
Equal Opportunity Employer
We are an Equal Opportunity Employer and are committed to fostering a diverse and inclusive workplace. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, gender identity, sexual orientation, pregnancy, national origin, age, disability, genetic information, veteran status, or any other characteristic protected by applicable federal, state, or local laws.
Job Type: Full-time
Pay: $100,000.00 - $105,000.00 per year
Benefits:
401(k)
401(k) matching
Dental insurance
Disability insurance
Employee assistance program
Employee discount
Flexible schedule
Flexible spending account
Health insurance
Health savings account
Life insurance
Paid time off
Parental leave
Professional development assistance
Referral program
Retirement plan
Travel reimbursement
Vision insurance
Application Question(s):
Have you worked for a health plan that services Medicare members?
Do you have experience independently writing denial letters using clinical rationale (not relying solely on templates)?
Experience:
Preservice/Prior Authorization: 1 year (Required)
Medicare Advantage : 1 year (Required)
CMS Guidelines: 1 year (Required)
Language:
Fluent Spanish (Preferred)
License/Certification:
CALIFORNIA RN/LVN License (CA is not compact) (Required)
Work Location: Remote
