Utilization Management Remote California License
Utilization Management Remote California License
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Salary Not Disclosed
1 Vacancy
Job Description
Job Title: Care Review Clinician II (RN or LVN) Remote
Location: Remote (Must have active CA license and be available during Pacific Standard Time hours)
Pay Rate: Up to $45/hour
Job Type: TemptoPerm
About the Role:
A leading Managed Care Organization is seeking an experienced and detailoriented Care Review Clinician II (RN or LVN) to join their Utilization Management team. This remote position plays a key role in reviewing clinical service requests supporting continuity of care and ensuring appropriate costeffective healthcare decisions are made in compliance with regulatory and clinical guidelines.
Key Responsibilities:
Perform clinical reviews of service requests including concurrent and prior authorization determinations
Serve as clinical support to the Continuity of Care (COC) and Community Support teams
Determine whether requests meet COC or community support criteria and escalate for MD review when needed
Conduct provider outreach as appropriate to support authorizations and care coordination
Utilize InterQual and other clinical guidelines to assess medical necessity and appropriate length of stay
Ensure documentation meets compliance quality and turnaround standards
Create and manage authorizations in accordance with established UM processes
Participate in team meetings and collaborate with other departments to support member care
Required Qualifications:
Active unrestricted LVN or RN license in California
35 years of clinical experience (inpatient outpatient or hospital setting strongly preferred)
Prior experience in Utilization Management Concurrent Review or Prior Authorization
Strong analytical and critical thinking skills in a fastpaced metricdriven environment
Solid computer proficiency including ability to toggle between multiple databases and tools
Experience using InterQual or similar medical necessity criteria tools
Knowledge of HIPAA and regulatory compliance standards
Excellent verbal and written communication skills
Preferred Qualifications:
Experience in Managed Care Health Plans or payerside healthcare operations
Familiarity with NCQA standards
Previous case management or care coordination experience
Additional Information:
Must provide your own secure and quiet workspace for remote work
Equipment (laptop monitors etc. will be provided by the organization
Must be available to work 8hour shifts during PST business hours MondayFriday
Employment Type
Hourly
