Utilization Management Review Nurse – Outpatient Prior Authorization (California RN)

Overview:

Our client, a Medical Center facility under the aegis of a California Public Ivy university and one of largest health delivery systems in California, seeks an accomplished

Utilization Management Review Nurse – Outpatient Prior Authorization (California RN) .

*** Candidate must be authorized to work in USA without requiring sponsorship ***

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*** Location: Los Angeles, CA 90045 *** Duration: 13-week contract with the possibility of extensions

Notes: 100% Remote role. Work Schedule: Monday to Friday, 8 AM – 5 PM (Pacific Time).

Description: The Utilization Management Review Nurse is responsible for the review and evaluation of clinical information and documentation related to outpatient prior authorization requests for medical services. This role requires independent review of clinical documentation, interpretation of medical records, and application of evidence-based medical necessity criteria in alignment with CMS, Medicare, Medi-Cal, CCS, regulatory, accreditation, and departmental requirements. The nurse independently determines medical necessity, level of care, and authorization outcomes including approval, denial, or referral to a Medical Director when criteria are not met. The role requires clear and defensible documentation of clinical rationale to support determinations while meeting strict turnaround times in a high-volume production environment. The Utilization Management Review Nurse collaborates with physicians, interdisciplinary clinical teams, payers, and internal departments to coordinate resolution of authorization requests. The position serves as a clinical resource to external teams such as customer service and claims and participates in performance improvement initiatives as assigned.

Qualifications: Completed BSN required. Must have California RN license. Must have prior authorization experience in an outpatient setting. Must have health plan, managed care organization, IPA, MSO, or healthcare plan administrator experience. Prior Authorization Nurse / Clinical Review Nurse background required. Current unrestricted Registered Nurse (RN) license in the state of California. Minimum of 3 years of utilization management or prior authorization experience in an outpatient setting. Direct experience performing outpatient prior authorization reviews within a health plan, managed care organization, IPA, MSO, or healthcare plan administrator environment. Independent approval and denial authority with demonstrated ability to refer cases to a Medical Director when appropriate. Experience applying evidence-based medical necessity criteria including InterQual, MCG (Milliman), CMS, and health plan-specific guidelines. Strong working knowledge of Medicare, Medi-Cal, CMS, and CCS utilization review requirements and regulations. Demonstrated ability to independently review clinical documentation and determine medical necessity and level of care. Strong background in abstracting and interpreting medical records to support utilization review decisions. Proven ability to manage a high-volume caseload in a fast-paced remote or office-based production environment. Experience communicating medical necessity determinations to physicians, clinical staff, payers, and internal departments. Ability to effectively communicate medical necessity and level-of-care criteria required for acute care hospitalization. Proficient computer skills including Microsoft Word, Excel, internet research, and managed care systems such as EZ Cap, Diamond, and IDX. Strong critical thinking, analytical skills, organizational skills, and ability to set priorities effectively. Self-directed, assertive, and resourceful with effective written and verbal communication skills. Ability to work effectively and collaboratively with interdisciplinary teams. Clinical experience sufficient to understand and communicate medical diagnoses and treatment plans to professional and non-professional personnel. Strong communication skills and the ability to confidently articulate medical necessity decisions to physicians, staff, and payers are essential.

Nice to haves: 3–5 years of utilization management experience. Remote work experience within a managed care environment. Experience participating in performance improvement projects and process initiatives. Experience developing individualized case management plans addressing physical, vocational, psychosocial, financial, and educational needs.

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I'd love to talk to you if you think this position is right up your alley, and assure a prompt communication, whichever direction. If you're looking for rewarding employment and a company that puts its employees first, we'd like to work with you.

Satwinder “Sat” Singh Lead Technical Recruiter

Company Overview:

Amerit Consulting

is an extremely fast-growing staffing and consulting firm. Amerit Consulting was founded in 2002 to provide consulting, temporary staffing, direct hire, and payrolling services to Fortune 500 companies nationally, as well as small to mid-sized organizations on a local & regional level. Currently, Amerit has over 2,000 employees in 47 states. We develop and implement solutions that help our clients operate more efficiently, deliver greater customer satisfaction, and see a positive impact on their bottom line. We create value by bringing together the right people to achieve results. Our clients and employees say they choose to work with Amerit because of how we work with them - with service that exceeds their expectations and a personal commitment to their success. Our deep expertise in human capital management has fueled our expansion into direct hire placements, temporary staffing, contract placements, and additional staffing and consulting services that propel our clients’ businesses forward.

Amerit Consulting provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws. This policy applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation and training. Applicants, with criminal histories, are considered in a manner that is consistent with local, state and federal laws.