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UM Review Nurse
Astrana Health. Utilize clinical judgement to approve or deny outpatient medical services for patients based on Medical Necessity Criteria and respective Health Plans .
Posted 10/27/2026full-timeMonterey Park • California • United StatesJunior💰 $34 - $47 per hourWebsite
Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in Utilization Review and Management, with a strong focus on outpatient medical services and compliance with state and federal regulations. Proficient in collaborating with healthcare teams and educating staff to ensure adherence to Medical Necessity Criteria and health plan standards.
Highest-signal resume keywords
CA-Licensed Utilization Review NurseOutpatient Utilization Management ExperienceActive LVN Or RN License In CaliforniaHealth Plan, IPA Or MSO ExperienceMicrosoft Applications Proficiency
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Utilization ReviewMedical Necessity CriteriaPrior AuthorizationRetrospective ReviewElective Inpatient AdmissionsOutpatient ProceduresDurable Medical EquipmentState And Federal RegulationsAccreditation StandardsInternal Policies Compliance
Soft Skills
Strong Interpersonal SkillsCollaborationStaff Education And Training
Tools & Technologies
Microsoft WordMicrosoft ExcelMicrosoft Outlook
Certifications & Qualifications
CA-Licensed Utilization Review NurseActive LVN Or RN License
Industry Keywords
Utilization ManagementHealth PlansIPAMSOOutpatient Services
About the role
Key responsibilities & impact- Utilize clinical judgement to approve or deny outpatient medical services for patients based on Medical Necessity Criteria and respective Health Plans
- Complete prior authorization/retrospective review of elective inpatient admissions, outpatient procedures, post-homecare services, and durable medical equipment
- Refer cases to Medical Directors as needed/appropriate
- Maintain knowledge of state and federal regulations and accreditation standards
- Comply with internal policies and procedures
- Perform any other job duties as requested
Requirements
What you’ll need- CA-licensed Utilization Review Nurse
- Candidates must live in California
- At least one year of outpatient Utilization Management experience in a fast-paced setting
- Active and unrestricted LVN or RN license in California
- Experience with Microsoft applications such as Word, Excel, and Outlook
- Two (2) years of health plan, IPA or MSO experience
- Strong interpersonal skills
- Ability to collaborate with co-workers, senior leadership, and other management
- Experience educating and training staff
Benefits
Comp & perks- Remote position
- Candidates within a 30 mile radius of the office may be expected to work hybrid
- Open availability between 8 AM - 8 PM PST, M-Su
- 5 shifts per week
- Nurses rotate weekend and holiday coverage
- Overtime is required
- Equal Employment Opportunity and Affirmative Action employer
- Disability accommodations available during the application process