Description

You will conduct concurrent utilization reviews to ensure medical necessity of inpatient and skilled nursing services, collaborating with providers and payers. Your work supports timely care transitions and compliance with clinical guidelines.

Requirements

• Active unrestricted RN or LVN/LPN license in California
• 2-3 years clinical nursing experience
• 1+ year in utilization review or case management
• Knowledge of InterQual, MCG, and managed care guidelines
• Strong communication and documentation skills

Responsibilities

• Conduct timely concurrent reviews for medical necessity using InterQual/MCG
• Collaborate with Medical Director on complex cases and provide clinical summaries
• Process authorization requests and communicate with providers and payers
• Support discharge planning and care coordination with case managers
• Maintain accurate documentation and ensure regulatory compliance