Utilization Review RN – Intensive Case Management, Medicare Advantage

UCLA Health

. Perform utilization review of medical necessity and appropriateness, cost containment and efficiency, compliance with regulations and contracts, care coordination and continuity of care, prior authorization and denial management, education and provider support, and data and quality reporting for Medicare Advantage referrals.

Posted 11/10/2026full-timeLos Angeles • California • United StatesJuniorMid-Level💰 $143,675 - $185,811 per yearWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in utilization management, including clinical documentation review, compliance with CMS guidelines, and effective care coordination. Proficient in problem-solving and prioritization to ensure quality patient care while managing resources efficiently.

Highest-signal resume keywords

Utilization Management ExperienceCMS Guidelines KnowledgeClinical Documentation ReviewProblem-Solving SkillsElectronic Health Records Familiarity

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Utilization ReviewClinical Documentation ReviewCritical ThinkingEvidence-Based Decision MakingCost ContainmentData ReportingPrior Authorization ManagementDenial ManagementHome Health Coverage CriteriaDME Regulations

Soft Skills

Excellent Communication SkillsOrganizational SkillsTime Management SkillsInterpersonal SkillsFlexibility

Tools & Technologies

Utilization PlatformsElectronic Health RecordsWindows Operating SystemMicrosoft ExcelMicrosoft WordMicrosoft PowerPointInternet Navigation

Industry Keywords

Medicare AdvantageCare CoordinationQuality CareResource UtilizationHealthcare Needs

About the role

Key responsibilities & impact

Perform utilization review of medical necessity and appropriateness, cost containment and efficiency, compliance with regulations and contracts, care coordination and continuity of care, prior authorization and denial management, education and provider support, and data and quality reporting for Medicare Advantage referrals.
Ensure home health and durable medical equipment services are cost effective, timely, and compliant.
Balance member quality care with efficient resource utilization under UCLA Medical Group Utilization Management guidelines.
Collaborate with patients, Faculty Practice Group, community resources, other providers, managed care operations, UCLA Health System, and health plans.
Implement, identify, coordinate, and monitor options and services to meet at-risk patients’ healthcare needs.
Work under the direction of the Assistant Director.

Requirements

What you’ll need

Minimum of 2 years’ experience in utilization management, Inpatient CM or clinical Experience.
Strong knowledge of CMS guidelines, home health coverage criteria, and DME regulations.
Proficient in clinical documentation review, critical thinking and evidence-based decision making.
Familiarity with utilization platforms and electronic health records.
Strong problem-solving skills and ability to analyze problems and formulate plans, solutions and a course of action given changing circumstances.
Excellent organizational and time management skills, including the ability to handle multiple conflicting priorities simultaneously.
Strong ability to prioritize.
Proficiency in computer skills including Windows computer function, computer navigation, and computerized patient care systems.
Competence navigating the internet/intranet and using browser software such as Microsoft Explorer and applications such as Excel, Word, and PowerPoint.
Excellent interpersonal, verbal and written communication skills.
Ability to articulate clinical and non-clinical information to individuals of all levels of understanding.
Ability to be flexible and work according to the availability of office personnel, patients, and resources required to coordinate patient care.
Final candidate accepting employment must disclose certain final administrative or judicial misconduct decisions within the last seven years, or appeals of substantiated misconduct findings with a previous employer.