Description

Perform real-time clinical reviews to ensure medical necessity and appropriateness of healthcare services. Collaborate with medical directors, coordinate care transitions, and ensure compliance with health plan policies.

Requirements

• Active California RN license
• Minimum 2-3 years clinical nursing experience
• At least 1 year in utilization review or case management
• Experience in managed care with medical necessity reviews preferred
• BSN preferred

Responsibilities

• Conduct timely concurrent reviews of inpatient and skilled nursing services for medical necessity
• Escalate complex cases to Medical Director with clinical summaries
• Process authorization requests and communicate with providers and payers
• Support discharge planning and care coordination with case managers
• Maintain accurate documentation for compliance with regulations and accreditation standards