About This Position
Pay Rate: $45–$50 per hour (DOE)
Location: Fully Remote – California residents only
Schedule: Monday–Friday, 9:00 AM–6:00 PM
Position Type: Temporary, approximately 3–6 months
Job Summary
The Utilization Management RN supports by reviewing medical service requests for medical necessity, quality, and cost-effectiveness. This role conducts pre-service and concurrent reviews, applies evidence-based clinical guidelines, and coordinates care for members with complex medical needs while ensuring compliance with state and federal regulations.
Key Responsibilities
Review inpatient and outpatient service requests and make authorization determinations within required regulatory timeframes.
Conduct pre-service and concurrent reviews using established clinical criteria, medical policies, and state and federal guidelines.
Evaluate medical necessity, level of care, member eligibility, and coverage requirements.
Escalate requests that do not meet clinical criteria to the Medical Director for secondary review.
Coordinate complex cases using case management principles, including assessment, care planning, implementation, and follow-up.
Prepare case presentations and participate in case reviews and interdisciplinary team meetings.
Coordinate urgent and emergency care for members receiving services outside the network or service area.
Support safe inpatient discharges by communicating member needs with care managers, providers, facilities, and primary care teams.
Help coordinate transitions back into the provider network when appropriate.
Qualifications & Requirements
Active California Registered Nurse (RN) license.
Minimum of 3 years of medical-surgical nursing experience.
Minimum of 3 years of Utilization Management and/or Prior Authorization experience.
Extensive UM and Prior Authorization experience, preferably in a managed care or health plan setting.
Strong inpatient and/or outpatient utilization review experience.
Transplant experience highly preferred.
Medical Assistant (MA) experience required.
Knowledge of Medicare, Medi-Cal, and California managed care regulations.
Strong clinical judgment, communication, organization, and care coordination skills.
Interested? Apply today!
Pay: $45.00 - $50.00 per hour
Experience:
Utilization management: 3 years (Required)
Medical-surgical: 3 years (Required)
License/Certification:
RN License (Required)
Location:
California (Required)
Work Location: Remote
Experience
Inpatient experience, Medicare, RN License, Medicaid health insurance, Managing patients as a nurse case manager, Medical-surgical, Pre-authorization review for utilization management, Medicare regulations, Utilization management, Resource utilization in healthcare, Organizational skills, Medicaid regulations, Medicaid, Medical assisting, Surgical nursing expertise
