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.

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

• Review daily census, prioritize cases, request pertinent 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 transition or closure criteria.

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

• Identify and address gaps in care, obstacles to discharge, readmission risks, and service delays.

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

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

• Escalate 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 coordinate transitions.

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

• Support customer or auditor visits, special projects, peer consultations, and other assigned responsibilities.

⛳️ Requirements

• Must currently reside in California.

• Active, unrestricted California RN licensure.

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

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

• Internet connection via cable broadband or fiber optic service with a minimum of 10 Mbps download and 5 Mbps upload for remote work.

• Bachelor’s degree in nursing or a related field is preferred.

• Capability to assess complex clinical data, recognize barriers, propose solutions, and make informed decisions.

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

• Ability to work independently, manage competing priorities, and collaborate in a dynamic, matrixed environment.

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

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

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

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

🏝️ Benefits

• Eligibility for an annual bonus plan.

• Medical insurance coverage.

• Vision insurance.

• Dental insurance.

• Well-being and behavioral health programs.

• 401(k) retirement plan.

• Company-paid life insurance.

• Tuition reimbursement assistance.

• Minimum of 18 days of paid time off per year.

• Paid holidays.

• Leaves of absence.

• Remote work arrangement available.

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