Utilization Review Nurse

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 elevate 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 elevate concerns requiring review to the UM Outpatient Clinical Supervisor. Evaluate requests for non-para-providing 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. Equal Opportunity Employer 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. #J-18808-Ljbffr