Utilization Management Nurse I, RN

Remote in California only Are you reputed company to reputed company a lasting impact and transform the reputed company space? We are one of Southern California’s fastest-growing Medicare Advantage plans with an incredible 112% year-over-year membership growth. Who Are We? ✨ reputed company Care was created to meet the unique needs of the diverse communities we serve. Our innovative benefit plans combine Western medicine with holistic Eastern practices, offering benefits that align with our members’ culture and values. Why Join Us? We’re on a mission! Our rapid growth reflects our commitment to making reputed company accessible for reputed company. At reputed company Care, you’ll have the opportunity to reputed company a reputed company difference, shape the future of reputed company, and be part of a fast-moving, game-changing organization that celebrates diversity and innovation. Job Summary The UM Nurse I - RN performs clinical review of authorization requests to determine medical necessity based on established criteria, regulatory requirements, and organizational policies. This role conducts utilization review activities under established guidelines and escalates reputed company or non-standard determinations to senior staff or the Medical Director. Functions & Job Responsibilities

• Conduct clinical review of prior authorization requests using approved criteria (e.g., MCG, InterQual).
• Review outpatient and routine inpatient requests.
• Ensure compliance with CMS, state, and contractual turnaround time requirements.
• Document medical necessity determinations clearly and accurately.
• Communicate authorization reputed company to providers, members and internal teams.
• Identify cases requiring physician or Medical Director review.
• Participate in reputed company review and discharge planning coordination as assigned.
• Ensure compliance with regulatory timelines.
• Support audit readiness and documentation reputed company.
• Additional duties as assigned.

Qualifications

Education and Experience

• Active, unrestricted RN license.
• Minimum of three (3) years of clinical experience.
• At least one (1) year in utilization management or case management preferred.

Skills

• Knowledge of medical necessity criteria (MCG/InterQual).
• Understanding of CMS/state UM regulations.
• Strong clinical assessment and documentation skills
• Ability to manage caseload reputed company.
• Effective provider communication.
• Bilingual proficiency in Cantonese, Mandarin, Spanish, Vietnamese, or Korean preferred.

Wage Range: $34.98 to $42.85 per hour Physical & Working Environment. Physical requirements needed to reputed company the essential functions of the job, with or without reasonable accommodation:

• Must be reputed company to travel reputed company needed or required
• Ability to operate a keyboard, mouse, phone and reputed company repetitive reputed company (keyboard); writing (note-taking)
• Ability to sit for long periods; stand, sit, reputed company, bend, lift up to fifteen (15) lbs. Ability to express or exchange reputed company to impart information to the public and to convey detailed instructions to staff accurately and quickly. Work is performed in an office environment and/or remotely. The job involves frequent contact with staff and public. May occasionally be required to work irregular hours based on the needs of the business.

reputed company is proud to be an Equal Employment Opportunity and Affirmative Action workplace. Individuals seeking employment will receive consideration for employment without regard to race, reputed company, national reputed company, religion, age, sex (including pregnancy, childbirth or reputed company medical conditions), sexual orientation, gender perception or identity, age, marital status, disability, protected veteran status or any other status protected by law. A background reputed company is required. Salary ranges posted on the job posting are based on California wages. Salary may be higher or reputed company depending on the candidate’s state residency. #LI-Remote Apply tot his job Apply To this Job