Registered Nurse – Utilization Management

This is a fully remote position, open to applicants in California.

📋 Description

• Evaluate and establish suitable levels of care utilizing InterQual, MCG, and the CMS Two-Midnight Rule.

• Perform initial and ongoing assessments for inpatient, observation, and outpatient/procedural services.

• Refer cases to the UM Medical Director, UM Physician Advisor, or external physician reviewer when necessary.

• Collaborate with physicians, care coordinators, and interdisciplinary teams regarding patient classification, care advancement, and transitions of care.

• Confirm physician orders and ensure adherence to Medicare, Medicaid, and payer regulations.

• Obtain reimbursement resources for patients who are uninsured or underinsured.

• Relay clinical information to third-party payers.

• Monitor and secure payer authorizations while averting coverage lapses.

• Review and contest concurrent denials; support with appeals and peer-to-peer discussions.

• Oversee length of stay, care advancement, resource utilization, and discharge barriers.

• Uphold confidentiality, regulatory compliance, and precise documentation.

⛳️ Requirements

• An associate degree or college diploma from an accredited nursing program — minimum requirement.

• A minimum of 3 years of acute nursing experience.

• RN state licensure — minimum requirement.

• Basic Life Support (BLS) certification — minimum standard.

• A bachelor's degree in Nursing — preferred qualification.

• At least 2 years of case management experience — preferred.

• Minimum of 1 year of CPT coding experience — preferred.

• Strong clinical judgment, critical thinking, and communication capabilities.

• Ability to operate both independently and collaboratively within a dynamic, multidisciplinary environment.

• Familiarity with InterQual, MCG, and CMS Two-Midnight Rule guidelines.

• Understanding of Medicare, Medicaid, and other payer regulations.

🏝️ Benefits

• Comprehensive health insurance options.

• Retirement savings plan with employer matching.

• Paid time off and flexible scheduling.

• Opportunities for professional development and continuing education.

• Supportive work environment focused on team collaboration.