Utilization Review Nurse

Utilize clinical judgment to approve or deny outpatient medical services based on Medical Necessity Criteria for various Health Plans Complete prior authorization and retrospective review of elective inpatient admissions, outpatient procedures, post-homecare services, and durable medical equipment Refer cases to Medical Directors as needed or appropriate Maintain knowledge of state and federal regulations and accreditation standards Comply with internal policies and procedures Perform other job duties as requested Requirements Active and unrestricted LVN license in California At least 1 year of outpatient Utilization Management experience Experience with Microsoft Word, Excel, and Outlook Candidates must live in California At least 2 years of health plan, IPA, or MSO experience preferred as a strong fit Strong interpersonal skills Ability to collaborate with co-workers, senior leadership, and other management Experience educating and training staff Core Competencies Demonstrates expertise in outpatient Utilization Management, applying clinical judgment to assess medical necessity and ensure compliance with state and federal regulations. Proficient in collaborating with healthcare teams and educating staff to enhance service delivery. Highest-signal resume keywords Active LVN License in California Outpatient Utilization Management Experience Health Plan Experience Microsoft Office Proficiency Interpersonal Skills Hard Skills Clinical Judgment Prior Authorization Retrospective Review Medical Necessity Criteria Elective Inpatient Admissions Outpatient Procedures Durable Medical Equipment Review State and Federal Regulations Knowledge Accreditation Standards Compliance Soft Skills Strong Interpersonal Skills Collaboration Staff Education and Training Certifications & Qualifications Active LVN License Industry Keywords Utilization Management Health Plans IPA MSO Medical Directors Tools & Technologies Microsoft Word Microsoft Excel Microsoft Outlook #J-18808-Ljbffr