Job Description

Utilization Review Nurse 2752904

A leading medical institution is seeking a Utilization Review Nurse . The successful candidate will ensure appropriate, cost-effective, and high-quality care for new century health plan members. The ideal candidate has a current valid California RN license.

Utilization Review Nurse Pay and Benefits:

• Hourly pay: $65/hr
• Worksite: Leading medical institution (Los Angeles, CA 90045 - Open to remote candidates in the United States)
• W2 Employment, Group Medical, Dental, Vision, Life, Retirement Savings Program
• 40 hours/week, 2 Month Assignment, Possible extension

Utilization Review Nurse Responsibilities:

• Ensure appropriate, cost-effective, and high-quality care for new century health plan members.
• Conduct utilization management (UM) activities in accordance with health plan policies and regulatory guidelines
• Identify and report potential quality issues and support provider dispute resolution processes to ensure compliance and foster provider satisfaction.
• Complete other duties as assigned.

Utilization Review Nurse Qualifications:

• 2+ years of experience in utilization management, preferably in medicare advantage or managed care.
• BSN or MSN degree.
• Current valid California RN license.
• Experience with potential quality issues (PQI) identification and reporting.
• Knowledge of medicare advantage regulatory guidelines, including CMS regulations.
• Familiarity with provider dispute resolution (PDR) processes.
• Strong clinical assessment and critical thinking skills.
• Proficiency in electronic health records (EHR) and utilization management software.

Utilization Review Nurse Shift:

• 5 days a week, 8 hours per day from 08:00 am to 05:00 pm.

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