Utilization Review Nurse

Job Description

Job Description

Position Overview

The Utilization Review Nurse is responsible for coordinating care and ensuring the medical necessity and appropriateness of services through effective communication, clinical review, and adherence to regulatory and organizational guidelines. This role works collaboratively with providers and internal departments to support timely, compliant, and high-quality patient care outcomes.

Key Responsibilities

• Serve as a primary point of contact for contracted providers and internal staff , ensuring clear and timely communication regarding care coordination, referrals, and organizational policies and procedures.
• Collaborate with Member Services and Provider Relations to address quality of care concerns and grievance cases, facilitating timely and effective resolution.
• Review and process referrals for Durable Medical Equipment (DME), home health, and outpatient services , applying clinical guidelines and Medi-Cal criteria to determine medical necessity and benefit coverage.
• Identify and escalate cases involving quality of care issues, coordination of benefits, and third-party liability as appropriate.
• Maintain comprehensive knowledge of covered benefits across all programs to ensure accurate determination and processing of requests.
• Assess cases for referral to internal programs, including Case Management, Transitions of Care, Major Organ Transplant, and Community Support Services (e.g., Enhanced Care Management) .
• Identify authorization-related issues and escalate concerns requiring review to the UM Outpatient Clinical Supervisor .
• Evaluate requests for non-par provider services and coordinate review with the Medical Director based on provider availability within the member’s geographic area.
• Prepare and process member and provider correspondence , including denial letters, ensuring accuracy, compliance, and timely distribution.
• Determine medical appropriateness and necessity of care in accordance with established criteria and mandated turnaround times .
• Refer cases that do not meet medical necessity criteria to the Medical Director for further review .
• Maintain up-to-date knowledge of California Children’s Services (CCS) guidelines to support coordination of services.
• Perform additional duties as assigned to support departmental goals and operational needs.

Required Skills

• Utilization Review
• Outpatient Coding

Qualifications

Education & Experience:

• Active, unrestricted Registered Nurse (RN) license (California)
• Minimum of 2 years of clinical experience in acute care, public health, community health, or chronic disease management
• Bachelor’s degree in Nursing, Health Administration, or a related healthcare field preferred

Preferred Qualifications:

• Experience with Utilization Management (UM) principles and processes
• Familiarity with MCG clinical guidelines and Medi-Cal coverage criteria
• Experience in case management or care coordination
• Knowledge of community resources for seniors and individuals with disabilities (Kern County preferred)

Additional Requirements

• Valid California Driver’s License and proof of auto liability insurance (up to 10% travel required)
• Bilingual (English/Spanish) preferred

Job Type & Location

This is a Contract to Hire position based out of Bakersfield, CA.

Pay and Benefits

The pay range for this position is $51.00 - $51.00/hr.

Eligibility requirements apply to some benefits and may depend on your job classification and length of employment. Benefits are subject to change and may be subject to specific elections, plan, or program terms. If eligible, the benefits available for this temporary role may include the following:
• Medical, dental & vision
• Critical Illness, Accident, and Hospital
• 401(k) Retirement Plan – Pre-tax and Roth post-tax contributions available
• Life Insurance (Voluntary Life & AD&D for the employee and dependents)
• Short and long-term disability
• Health Spending Account (HSA)
• Transportation benefits
• Employee Assistance Program
• Time Off/Leave (PTO, Vacation or Sick Leave)

Workplace Type

This is a fully onsite position in Bakersfield,CA.

Application Deadline

This position is anticipated to close on Jun 4, 2026.

About TEKsystems

We're partners in transformation. We help clients activate ideas and solutions to take advantage of a new world of opportunity. We are a team of 80,000 strong, working with over 6,000 clients, including 80% of the Fortune 500, across North America, Europe and Asia. As an industry leader in Full-Stack Technology Services, Talent Services, and real-world application, we work with progressive leaders to drive change. That's the power of true partnership. TEKsystems is an Allegis Group company.

The company is an equal opportunity employer and will consider all applications without regards to race, sex, age, color, religion, national origin, veteran status, disability, sexual orientation, gender identity, genetic information or any characteristic protected by law.

About TEKsystems and TEKsystems Global Services

We’re a leading provider of business and technology services. We accelerate business transformation for our customers. Our expertise in strategy, design, execution and operations unlocks business value through a range of solutions. We’re a team of 80,000 strong, working with over 6,000 customers, including 80% of the Fortune 500 across North America, Europe and Asia, who partner with us for our scale, full-stack capabilities and speed. We’re strategic thinkers, hands-on collaborators, helping customers capitalize on change and master the momentum of technology. We’re building tomorrow by delivering business outcomes and making positive impacts in our global communities. TEKsystems and TEKsystems Global Services are Allegis Group companies. Learn more at TEKsystems.com.

The company is an equal opportunity employer and will consider all applications without regard to race, sex, age, color, religion, national origin, veteran status, disability, sexual orientation, gender identity, genetic information or any characteristic protected by law.

San Francisco Fair Chance Ordinance: Pursuant to the San Francisco Fair Chance Ordinance, for all positions located in the city and county of San Francisco, we will consider for employment qualified applicants with arrest and conviction records.

Massachusetts Lie Detector: It is unlawful in Massachusetts to require or administer a lie detector test as a condition of employment or continued employment. An employer who violates this law shall be subject to criminal penalties and civil liability.

Use of Artificial Intelligence (AI): We may use Artificial Intelligence (AI) to support parts of our hiring process, including sourcing, screening, and evaluating candidates. AI helps assess applications and qualifications, but final decisions are made by our hiring team. By applying, you acknowledge and agree that your application may be reviewed using AI tools.