Utilization Management Nurse, RN

IEHP

. Conduct prospective, concurrent, and retrospective reviews for medical necessity and appropriateness of service and care, including specialist, outpatient and ancillary services, outpatient surgery, durable medical equipment, home health, and high dollar cases .

Posted 11/7/2026full-timeCalifornia • United StatesJuniorMid-Level💰 $91,250 - $120,910 per yearWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in Utilization Management (UM) processes, including medical necessity reviews and benefit interpretation, while effectively communicating complex medical information to diverse audiences. Possesses strong clinical assessment skills and a thorough understanding of regulatory requirements and standards of care.

Highest-signal resume keywords

Registered Nurse (RN) LicenseUtilization Management (UM) CriteriaClinical Assessment SkillsMedical Necessity StandardsKnowledge of Title 22 and Title 10

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Clinical Patient Care ExperienceDocumentation SkillsMedical TerminologyBenefit InterpretationDenial Review and AssessmentQuality Findings ReportingAbstracting Medical InformationDrafting Denial LanguageCase ManagementLEAN Methodology

Soft Skills

Communication SkillsCritical ThinkingAttention to DetailEfficiency in Caseload ManagementCollaboration with Physicians and Nursing Staff

Certifications & Qualifications

Active RN License

Industry Keywords

Managed CareHMOState Regulatory RequirementsCMSDMHCDHCSHealth Plan OperationsUM Policies and ProceduresClinical Standards of CareMedical Management Audits

About the role

Key responsibilities & impact

Conduct prospective, concurrent, and retrospective reviews for medical necessity and appropriateness of service and care, including specialist, outpatient and ancillary services, outpatient surgery, durable medical equipment, home health, and high dollar cases
Screen medical information and authorization requests for medical necessity and appropriateness against current criteria and discuss with Medical Directors
Review referral denials, denial letters, and logs to assess denial appropriateness, alternative treatment, case management, and quality-of-care issues
Collaborate with the UM Medical Director on reviews and final determinations
Draft denial language using standardized, nationally recognized UM criteria
Translate medical terminology into lay language and grade reading level as appropriate
Work with Medical Directors to ensure consistent use of guidelines and criteria
Create and maintain a standardized matrix of denial language by Line of Business
Partner in the letter of agreement process for out-of-network referrals
Review and report quality findings to UM Management monthly
Obtain additional medical-necessity information and research issues supporting benefit interpretation
Support the UM Team with benefit interpretation and UM policies and procedures
Support revisions to IEHP UM Subcommittee Guidelines
Attend staff meetings and education trainings
Participate in LEAN activities
Assist with utilization management sections of Medical Management audits and focused referral and denial audits
Perform other duties required for Health Plan operations and department business needs

Requirements

What you’ll need

A minimum of two (2) years of direct, hands-on clinical patient care experience in an acute care facility utilizing an active RN license is required.
Experience in an HMO or experience in a Managed Care setting preferred
High school diploma or GED required
Bachelor's degree in nursing from an accredited institution preferred
Possession of an active, unrestricted, and unencumbered Registered Nurse (RN) license issued by the California BRN required
Strong knowledge and understanding of nationally recognized UM criteria
Strong knowledge and understanding of Title 22, Title 10, DMHC, DHCS, CMS, and state regulatory requirements specifically as they relate to UM/Health Plan correspondence
Strong knowledge and understanding of clinical nursing practice, standards of care, and medical terminology
Strong knowledge and understanding of medical necessity standards and benefit interpretation
Strong proficiency in clinical assessment and documentation skills
Skills in documenting UM referral reviews accurately
Communication skills (both written and verbal)
Critical thinking skills
Ability to abstract and interpret medical information from clinical records
Ability to express or exchange ideas to impart information to the public and convey detailed instructions to staff accurately and quickly
Ability to manage caseload efficiently
High attention to detail
Ability to work at a high level of speed while maintaining accuracy
Ability to work well with both physicians and nursing staff

Benefits

Comp & perks

Competitive salary
Telecommute schedule
State of the art fitness center on-site
Medical Insurance with Dental and Vision
Life, short-term, and long-term disability options
Career advancement opportunities and professional development
Wellness programs that promote a healthy work-life balance
Flexible Spending Account – Health Care/Childcare
CalPERS retirement
457(b) option with a contribution match
Paid life insurance for employees
Pet care insurance