Utilization Management Clinical Reviewer

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

📋 Description

• Oversee and manage a designated caseload of intricate, high-acuity, or account-sensitive inpatient cases.

• Conduct prospective, concurrent, and retrospective clinical evaluations for acute inpatient care, rehabilitation, referrals, select outpatient services, and durable medical equipment, as necessary.

• Utilize approved clinical guidelines and tools to assess medical necessity, care levels, covered services, treatment objectives, risk factors, and discharge requirements.

• Monitor the daily census, prioritize cases, request necessary clinical information, and accurately document decisions, interventions, and outcomes in a timely manner.

• Develop member-focused short- and long-term care plans that include measurable objectives, follow-up timelines, and criteria for transition or closure.

• Collaborate with members, families, healthcare providers, facilities, vendors, caregivers, and internal stakeholders to facilitate timely discharge or transfer.

• Identify and assist in resolving care gaps, discharge barriers, readmission risks, and service delays.

• Inform members about benefits, care alternatives, costs, and community resources.

• Act as a member advocate and liaison within the framework of benefit, regulatory, contractual, and program requirements.

• Refer complex cases, quality-of-care issues, and service delays to managers, medical directors, or Quality partners.

• Identify referrals for complex or specialized case management programs and oversee transitions.

• Cultivate relationships with internal teams, providers, customers, and community resources.

• Assist with customer or auditor visits, special projects, peer consultations, and associated responsibilities.

⛳️ Requirements

• Must currently reside in California.

• Possess an active, unrestricted California RN license.

• At least two years of direct clinical RN experience in an inpatient or managed care environment.

• Bachelor's degree in nursing or a related discipline (preferred).

• Capability to evaluate complex clinical data, identify obstacles, suggest solutions, and make informed decisions.

• Strong skills in written and verbal communication, organization, time management, research, analysis, negotiation, and problem-solving.

• Ability to work independently, manage competing demands, and collaborate in a fast-paced, matrixed setting.

• Proficient in using computers and clinical or case management systems.

• Experience in medical management, utilization management, or case management within a health plan or hospital context.

• Knowledge of managed care products, care management strategies, and community, state, and federal resources.

• Proven ability to anticipate needs, coordinate services, and foster cooperative relationships with diverse internal and external partners.

• Must be available to work an 8-hour shift between 8:00 a.m. and 5:00 p.m. PST, Monday through Friday.

• Home internet connection must be via cable broadband or fiber optic service with a minimum of 10 Mbps download and 5 Mbps upload speeds.

🏝️ Benefits

• Eligibility for an annual bonus plan.

• Medical, vision, and dental coverage commencing on day one.

• Access to well-being and behavioral health programs starting on day one.

• 401(k) plan.

• Company-paid life insurance.

• Tuition reimbursement.

• A minimum of 18 days of paid time off annually.

• Paid holidays.

• Leaves of absence.

• Remote work arrangement.

• Requirement for cable broadband or fiber optic internet service for home-based work.