This role supports clinical operations by conducting complex clinical reviews and coordinating care to ensure medical necessity and benefit compliance. The selected candidate will use advanced clinical judgment and collaborate with internal and external stakeholders to ensure timely and appropriate care delivery.
Key Responsibilities
Conduct complex clinical reviews using advanced critical thinking and clinical judgment.
Act as a subject matter expert and mentor for LVN staff.
Ensure health plan performance meets Medicare, Medi-Cal, and commercial benchmarks.
Serve as a liaison between internal and external clinical teams to reduce barriers to care.
Provide feedback on process improvements and contribute to department strategy.
Support and influence project enhancements related to the Medical Management system.
Review and triage service requests for medical necessity and timeliness.
Present cases to the Medical Director when further clinical review is warranted.
Communicate outcomes with providers and members in accordance with regulations.
Ensure accurate documentation in internal systems per departmental policies.
Required Qualifications
Graduate of an accredited nursing program (ASN, ADN, BSN, or MSN). Bachelors preferred.
Active, unrestricted California RN license.
Advanced knowledge of medical necessity criteria and regulatory guidelines.
Minimum two years experience in a healthcare or managed care setting preferred.
Certification in CCM, URAC, or Managed Care Nursing is a plus.
Demonstrated leadership and mentoring capabilities.