About This Position
Medical Management Specialist RN (Utilization Management)
Location: Fully Remote – California residents only
Pay: $45–$50/hr DOE
Schedule: Monday–Friday, 9:00 AM–6:00 PM PST
Assignment: Temporary, approximately 3–6 months
Position Overview
A prominent healthcare organization is seeking an experienced Medical Management Specialist RN to support its Utilization Management (UM) team. This fully remote opportunity is ideal for an RN with extensive hands-on experience in Utilization Management, Prior Authorizations, and managed care operations.
The selected candidate will review medical services for medical necessity, evaluate authorization requests, and ensure compliance with applicable clinical guidelines and healthcare regulations.
Key Responsibilities
Review inpatient and outpatient authorization requests to determine medical necessity and appropriateness of care.
Perform clinical reviews in accordance with established guidelines, policies, and regulatory requirements.
Evaluate Prior Authorization requests and supporting medical documentation.
Collaborate with physicians, healthcare providers, and internal departments to coordinate utilization management activities.
Apply knowledge of Medicare, Medi-Cal, and California managed care regulations.
Maintain accurate documentation and ensure timely processing of authorization requests.
Minimum Qualifications
Active California Registered Nurse (RN) license.
Minimum 3 years of nursing experience.
Minimum 3 years of hands-on Utilization Management and/or Prior Authorization experience.
Extensive experience within a managed care organization or health plan setting.
Strong inpatient and/or outpatient Utilization Management experience.
Medical Assistant (MA) experience.
Knowledge of Medicare, Medi-Cal, and California managed care regulations.
Preferred Qualifications:
Transplant authorization or clinical review experience.
Experience working with Medicare Advantage or managed care health plans.
Additional Details
Fully remote position; candidates must reside in California.
Equipment provided by the client.
Monday–Friday schedule, 9:00 AM–6:00 PM PST.
Temporary assignment estimated at 3–6 months.
Pay: $45.00 - $50.00 per hour
Expected hours: 40.0 per week
Benefits:
Dental insurance
Health insurance
Vision insurance
Education:
Associate (Required)
Experience:
Prior authorization: 3 years (Preferred)
Utilization management: 3 years (Preferred)
License/Certification:
California RN License (Required)
Location:
California (Required)
Work Location: Remote
Experience
Health insurance verification via online portal, Insurance prior authorization, Medicare, RN License, Healthcare insurance patient portal navigation, Medicare regulations, Utilization management, Medicaid regulations, Medicaid, Medical assisting, Associate's degree, Nursing
Benefits
Health insurance, Dental insurance, Vision insurance
