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Utilization Management Nurse RN 5

Wollborg Michelson Recruiting

Oakland, CA

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JOB DETAILS
SKILLS
Agile Programming Methodologies, Case Management, Clinical Assessment, Clinical Medicine, Computer Skills, Cross-Functional, Detail Oriented, Disease Prevention and Control, Documentation, Emergency Care, Establish Priorities, Health Plan, Healthcare Quality, Hospital, Intensive Care, Internet Research, Internet Search, Leadership, Legal, Managed Care, Medical Coding, Medical Records, Microsoft Excel, Microsoft Word, Multitasking, Organizational Skills, Patient Care Denials, Presentation/Verbal Skills, Process Management, Quality of Care, Registered Nurse (RN), Regulatory Compliance, Time Management, Utilization Management
LOCATION
Oakland, CA
POSTED
1 day ago

Utilization Review Registered Nurse


Job Summary

Conducts utilization review of medical records for medical necessity, coding accuracy, medical policy compliance, and contract compliance. Supports post-service and prior authorization review processes and collaborates with clinical leadership to ensure appropriate care determinations.

Responsibilities
  • Triages and prioritizes cases to meet required turnaround times.
  • Prepares and presents cases electronically to the Medical Director for approval, denial, and medical necessity determinations.
  • Communicates determinations to providers in compliance with applicable regulatory and accreditation requirements.
  • Identifies potential quality of care issues and service or treatment delays and intervenes as clinically appropriate.
  • Provides referrals to Case Management, Disease Management, Appeals and Grievance, and Quality departments as needed.
  • Supports the development and implementation of a standardized, proactive approach to retrospective claims review from a clinical perspective.

Requirements
  • Active Registered Nurse (RN) license in California.
  • Minimum 2 years of experience working in an Agile environment.
  • Minimum 3 years of case management experience.
  • Strong clinical assessment and critical thinking skills.
  • Proficiency with computers, including Microsoft Word, basic Excel, and internet research.
  • Ability to work independently, prioritize workload, and manage multiple tasks effectively.

Preferred Qualifications
  • Clinical experience in hospital, emergency department, or intensive care settings.
  • Previous post-service review experience.
  • Previous prior authorization experience.
  • Additional case management experience in a managed care or health plan environment.

Certifications
  • Registered Nurse (RN), California.

Skills
  • Strong clinical judgment and decision-making skills.
  • Excellent organizational and time management abilities.
  • Ability to work independently with minimal supervision.
  • Strong attention to detail and documentation accuracy.
  • Proficiency with internet search tools and technology platforms.
  • Comfort working in a fast-paced, technology-driven environment.

Summary Qualification
  • Licensed Registered Nurse in California with substantial clinical background.
  • Experience in utilization review, case management, and managed care processes.
  • Demonstrated ability to evaluate medical necessity, quality of care, and policy compliance.
  • Skilled in electronic case presentation and communication with multidisciplinary teams.
  • Proficient with standard office software and online research tools.


Wollborg Michelson Recruiting is an Equal Opportunity Employer and prohibits discrimination of any kind. We ensure job offers are made based of one s employment experience, skills, and qualifications, regardless of race, gender, ethnic origin, or any other classification protected by law. All applicants must furnish proper identification to prove their legal right to work in the US upon a job offer. We participate in E-Verify to confirm one s right to work in the US. Wollborg Michelson Recruiting does not provide sponsorship for an employment-based visa status.

About the Company

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Wollborg Michelson Recruiting

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