Medical Management Specialist, RN – Part-time

SCAN

. Promote and support the quality, medical necessity, and cost effectiveness of care and services under state and federal regulations and Medical Policy .

Posted 10/2/2026part-timeRemote • California • United StatesMid-LevelSenior💰 $50 per hourWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in Utilization Management and Medical Case Management, with a strong focus on regulatory compliance and quality of care. Proficient in coordinating complex medical needs and collaborating with interdisciplinary teams to ensure effective patient outcomes.

Highest-signal resume keywords

California RN LicenseUtilization Management ExperienceMedical Case Management CertificationKnowledge of Medicare/Medi-CalICD-9, HCPCS, and CPT Coding Knowledge

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Utilization ManagementCase ManagementMedical Necessity AssessmentEvidence-Based Criteria ApplicationData EntryAnalytical SkillsProblem-Solving SkillsDocumentation MaintenanceCare CoordinationPatient Advocacy

Soft Skills

Verbal CommunicationWritten CommunicationMultitaskingRelationship BuildingTeam Collaboration

Tools & Technologies

Microsoft WordMicrosoft ExcelMicrosoft OutlookMicrosoft PowerPoint

Certifications & Qualifications

California RNCPUM CertificationCPUR Certification

Industry Keywords

Managed CareCalifornia Managed Care IndustryFederal Healthcare RegulationsState Healthcare RegulationsHealth Plan Contracting

About the role

Key responsibilities & impact

Promote and support the quality, medical necessity, and cost effectiveness of care and services under state and federal regulations and Medical Policy
Support utilization management processes related to coverage decisions and requests for items and services
Conduct pre-service and concurrent reviews using established guidelines in collaboration with the Medical Director
Apply case management principles to coordinate complex medical needs, care, and services
Ensure inpatient, outpatient, and other services are delivered at the right time, level of care, and location
Issue determinations within required regulatory timeframes
Collect relevant information and apply evidence-based criteria, regulations, Medical Policy, DOFR, and member eligibility requirements
Escalate requests to the Medical Director for secondary review when criteria are not met
Manage complex cases through assessment, planning, implementation, coordination, advocacy, monitoring, and evaluation
Prepare and deliver case presentations; participate in case rounds and interdisciplinary team meetings; incorporate recommendations into care plans
Assist members requiring urgent or emergent out-of-network or out-of-area medical and behavioral health services
Authorize stabilization services and transition members back to the SCAN network when appropriate
Facilitate safe and effective inpatient discharges by communicating member needs to care team members
Make referrals to clinical programs based on established criteria
Address urgent member quality or access issues through the Quality of Care process
Escalate workflow barriers to the supervisor or manager
Maintain documentation and data-entry requirements
Answer and return calls and correspondence according to telephone standards
Build professional relationships with providers and internal and external partners while maintaining confidentiality
Maintain professional and technical knowledge through education, publications, networking, and professional societies
Support SCAN’s vision and goals
Perform other duties as assigned

Requirements

What you’ll need

Part-time temporary role for approximately 3–6 months
California RN required
Nursing degree required
Current and active California RN required
CPUM or CPUR or other Medical Case Management certification preferred, or willingness to attain such certification within 2 years
3+ years of experience in medical-surgical nursing
3+ years of Utilization Management/Prior Authorization experience in a Managed Care medical group, IPA, or managed care setting
Knowledge of the California managed care industry and Medicare/Medi-Cal required
Knowledge of federal and state healthcare mandates and regulations
Health plan and vendor contracting knowledge
Proficiency in Microsoft Word, Excel, Outlook, and PowerPoint
Strong analytical and problem-solving skills
Strong verbal and written communication skills
Ability to multitask and work closely with department RNs
Ability to work well in a fast-paced and dynamic environment
ICD-9, HCPCS, and CPT coding knowledge
Background check required

Benefits

Comp & perks

Excellent 401(k) Retirement Saving Plan with employer match
Remote Work Mode
Opportunity to become part of a team that makes a difference to members and the community
Inclusive benefits and programs
Equal pay initiatives
Employee resource groups