Utilization Review Nurse

You are applying for a position through Medix, a staffing agency. The actual posting represents a position at one of our clients.


Job Summary


Our client is seeking a Utilization Review Nurse responsible for managing the complete Utilization Management (UM) process, from admission through discharge planning. The primary goal is to conduct daily inpatient reviews, concurrent reviews, discharge planning, and coordinating care for DME, Home Health, and Skilled Nursing Facility (SNF) placements.


Responsibilities / Job Duties

• Manage the beginning-to-end Utilization Management (UM) process through Discharge Planning.
• Conduct daily inpatient review, concurrent review, discharge planning, and coordinate care for DME, Home Health, and SNF placements.
• Utilize MCG criteria for clinical reviews and write formal denial letters.
• Apply LCD/NCD to pre-service authorizations when determining appropriate clinical tiers.
• Communicate confidently and effectively with Medical Directors, physicians, and hospital counterparts.
• Provide clear, concise clinical case reports during daily multidisciplinary rounds.

Minimum Education and Experience Qualification Requirements


Qualifications

• Active and unencumbered California RN or LVN License.
• Strongly prefer 5+ years of concurrent Inpatient UM experience.
• Direct experience working within an IPA, MSO, Delegation model, or Health Plan setting.
• Proven, hands-on experience navigating and applying MCG criteria for inpatient acute/SNF reviews.
• Experience in handling complex discharge planning, writing denial letters, and applying Medicare guidelines for SNF and ARU.
• Proficiency with standard digital workspace tools (Microsoft Excel, Word, and PDFs).

Skills

• Proficiency with MCG criteria and guidelines.
• Effective communication with medical staff and hospital counterparts.
• Technical skills with software tools such as Microsoft Excel, Word, and PDFs.

Schedule / Shift


Standard Shift: 8:00 AM - 5:00 PM PST, Monday through Friday, including a 1-hour lunch break, a morning break, and an afternoon break.


Benefits

• Paid Sick Leave (Medix provides paid sick leave according to state and local sick leave ordinances).
• Health Benefits / Dental / Vision (Medix offers 6 different health plans: 3 Major Medical Plans, 2 Fixed Indemnity Plans (Standard and Preferred), and 1 Minimum Essential Coverage (MEC) Plan. Eligibility for health benefits is based on verifying that an average of 30 hours per week during the first 4 weeks of the work assignment has been met. If you meet eligibility requirements and take action to enroll, you will be covered no earlier than 60 days into your assignment, depending on plan selection(s)).
• 401k (Eligible on the first 401k open enrollment date following 6 consecutive months on assignment. 401k Open Enrollment dates are 1/1, 4/1, 7/1, and 10/1).
• Short Term Disability Insurance.
• Term Life Insurance Plan.

* We will consider for employment all qualified Applicants, including those with criminal histories, in a manner consistent with the requirements of applicable federal, state, and local laws, including the City of Los Angeles' Fair Chance Initiative for Hiring Ordinance (FCIHO), Los Angeles Fair Chance Ordinance for Employers (ULAC), The San Francisco Fair Chance Ordinance (FCO), and the California Fair Chance Act (CFCA).


Medix Overview:


With over 20 years of experience connecting organizations with highly qualified professionals, Medix is a leading provider of workforce solutions for clients and candidates across the healthcare, scientific, technology, and government industries. Through our core purpose of positively impacting lives, we're dedicated to creating opportunities for job seekers at some of the nation's top companies. As an award-winning career partner, Medix is committed to helping talent find fulfilling and meaningful work because our mission is to help you achieve yours.


* As a job position within our Care Management division, a successful completion of a background check may be required as a condition of employment. This requirement is directly related to essential job functions including but not limited to: accessing financial and confidential information, access and handling of patient medical records, providing medical care inside a patient's residential address, driving, prescription and other drug access and administration, and working with vulnerable populations, such as, minors, elderly and those with physical or mental disabilities. Due to these job duties, this position has a significant impact on the business operations and reputation, as well as the safety and well-being of individuals who may be cared for as part of the job position or who may interact with staff or clients.