California Licensed Utilization Review Nurse

Job Summary

A company is looking for a Concurrent Utilization Review Nurse, RN (Work from Home).

Key Responsibilities:

• Conduct real-time clinical reviews to assess medical necessity and appropriateness of healthcare services
• Collaborate with the Medical Director on complex cases and ensure compliance with health plan policies
• Process authorization requests and facilitate communication with healthcare providers and payers

Qualifications:

• Registered Nurse (RN) with an active California nursing license; BSN preferred
• 2-3 years of clinical nursing experience, with at least 1 year in utilization review or case management
• Experience in a managed care setting with medical necessity reviews is preferred
• Preferred certifications include CPUR, CCM, or ACM
• Strong knowledge of clinical guidelines and proficiency in EHR and utilization management software