Utilization Review Nurse (RN) – Managed Care
Anaheim, CA (additional opportunities in Corona, CA)
** Position is available as Direct Hire/Permanent, or as a CONTRACT or CONTRACT-TO-HIRE role,
depending on what works best for each Candidate's situation! **
Utilization Review Nurse Job Summary:
Utilization Review Nurse Background:
- The Utilization Review Nurse is responsible for utilization management and utilization review for prospective (prior authorization), concurrent, or retrospective review.
- The Utilization Review Nurse will performs reviews of services, and determine medical appropriateness of inpatient and outpatient services following evaluation of medical guidelines and benefit determination.
- Utilize clinical skills to telephonically provide and facilitate utilization review, continued stay reviews and utilization management of all cases based on clinical experience and recognized guidelines.
- The Utilization Review Nurse will obtain the information necessary to assess a member's clinical condition, identify ongoing clinical care needs and ensure that members receive services in the most optimal setting to effectively meet their needs.
- Current, valid, and unrestricted state Registered Nurse (R.N.) license.
- CPUM/CPUR or CPHM (or similar) certification is preferred
- 2 years acute care clinical nursing experience, to include working with transplant patients/members is required.
- At least 3 year of recent experience in Utilization Review or Utilization Management at a health plan or other managed care organization (HMO/TPA/IPA/etc).
- Knowledge of guidelines for Medicaid/Medicare and related state programs is required.
- Experience using MCG (Milliman Care Guidelines) criteria for medical necessity, setting and level of care, and concurrent patient management.
- Computer skills to include Microsoft Word, Excel, database use, and basic data entry.