Utilization Review Nurse II

Utilization Review Nurse II

Primary Location Baldwin Park, California Facility Name Baldwin Park Hospital Employee Status: Regular Schedule Per Diem Scheduled Weekly Hours: 1 Shift Day Salary $84.61 - $97.83 / hour

Job Number 1452728 Date Posted 11/05/2026 Worker Location: Onsite

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Description:

Job Summary:

In addition to the responsibilities listed below, this position is also responsible for leveraging clinical knowledge of evidence-based guidelines, insurance policies, and clinical criteria to consult on the medical necessity, level of care, and duration of treatment required for standard reviews, and collaborating with the health care team, members, and caregivers to assist in discharge planning, cost of care options, and/or coordinating referrals to appropriate services based on medical necessity.

Essential Responsibilities:

• Pursues effective relationships with others by sharing resources, information, and knowledge with coworkers and members. Listens to, addresses, and seeks performance feedback. Pursues self-development; acknowledges strengths and weaknesses based on career goals and takes appropriate development action to leverage / improve them. Adapts to and learns from change, challenges, and feedback; demonstrates flexibility in approaches to work. Assesses and responds to the needs of others to support a business outcome.
• Completes work assignments by applying up-to-date knowledge in subject area to meet deadlines; follows procedures and policies, and applies data and resources to support projects or initiatives with limited guidance and/or sponsorship. Collaborates with others to solve business problems; escalates issues or risks as appropriate; communicates progress and information. Supports the completion of priorities, deadlines, and expectations. Identifies and speaks up for ways to address improvement opportunities.
• Supports high-quality consultation by: communicating with physicians, managers, staff, members, and/or caregivers regarding requirements related to medical necessity and benefit denials across the continuum of care, independently; and leveraging working knowledge to ensure the correct and consistent application, interpretation, and utilization of member health care benefits, cost of care options, and coverage by members and physicians.
• Supports education and compliance initiatives by: remaining up-to-date and discussing with the team the relevant state and federal regulations, guidelines, criteria, and documentation requirements that affect utilization management; and participating and providing feedback on education and training programs for staff and physicians at the local level to promote best practices in utilization management.
• Assists in quality improvement efforts by: observing and identifying utilization patterns, trends, and opportunities for improvement; learning about utilization review workflows/processes including corrective action plans and standard work, and identifying deficiencies in workflows; and learning and actively adhering to utilization policies, procedures, and guidelines to ensure compliant and cost-effective care.
• Performs utilization reviews by: following standard policies and procedures when conducting reviews of medical records and treatment plans to evaluate the medical necessity, appropriateness, and efficiency of requested health care services, under guidance; and assessing the ongoing need for services, identifying potential issues/delays, and recommending appropriate actions for standard member cases.

Knowledge, Skills and Abilities: (Core)

• Ambiguity/Uncertainty Management
• Attention to Detail
• Business Knowledge
• Communication
• Critical Thinking
• Cross-Group Collaboration
• Decision Making
• Dependability
• Diversity, Equity, and Inclusion Support
• Drives Results
• Facilitation Skills
• Health Care Industry
• Influencing Others
• Integrity
• Learning Agility
• Organizational Savvy
• Problem Solving
• Short- and Long-term Learning & Recall
• Teamwork
• Topic-Specific Communication

Knowledge, Skills and Abilities: (Functional)

• Medical Terminology
• Nursing Principles
• Acts with Compassion
• Confidentiality
• Consulting
• Evidence-Based Medicine Principles
• Quality Assurance and Effectiveness
• Relationship Building
• Written Communication

Minimum Qualifications:

• Bachelors Degree in Nursing AND minimum one (1) year of experience in direct patient care, utilization review/management, or discharge planning in a managed care setting or a directly related field.
• Registered Nurse License (California) required at hire

Preferred Qualifications:

• One (1) year of experience in utilization review/management.

Primary Location: California,Baldwin Park,Baldwin Park Hospital Scheduled Weekly Hours: 1 Shift: Day Workdays: Mon, Tue, Wed, Thu, Fri, Sat, Sun Working Hours Start: 09:00 AM Working Hours End: 05:30 PM Job Schedule: Per Diem Job Type: Standard Worker Location: Onsite Employee Status: Regular Employee Group/Union Affiliation: NUE-SCAL-01|NUE|Non Union Employee Job Level: Individual Contributor Department: Baldwin Park Med Center - Utilization Management - 0801 Pay Range: $84.61 - $97.83 / hour Kaiser Permanente strives to offer a market competitive total rewards package and is committed to pay equity and transparency. The posted pay range is based on possible base salaries for the role and does not reflect the full value of our total rewards package. Actual base pay determined at offer will be based on labor market data, internal alignment, and a candidate''s years of relevant work experience, education, certifications, skills, and geographic location. Travel: No On-site: Work location is on-site (KP designated office, medical office building or hospital). Worker location must align with Kaiser Permanente''s Authorized States policy. Kaiser Permanente is an equal opportunity employer committed to fair, respectful, and inclusive workplaces. Applicants will be considered for employment without regard to race, religion, sex, age, national origin, disability, veteran status, or any other protected characteristic or status.

For jobs where work will be performed in unincorporated LA County, the employer provides the following statement in accordance with the Los Angeles County Fair Chance Ordinance. Criminal history may have a direct, adverse, and negative relationship on the following job duties, potentially resulting in the withdrawal of the conditional offer of employment:

Consistently supports compliance and the Principles of Responsibility (Kaiser Permanente''s Code of Conduct) by maintaining the privacy and confidentiality of information, protecting the assets of the organization, acting with ethics and integrity, reporting non-compliance, and adhering to applicable federal, state, and local laws and regulations, accreditation, and licensure requirements (where applicable), and Kaiser Permanente''s policies and procedures.

Models and reinforces ethical behavior in self and others in accordance with the Principles of Responsibility, adheres to organizational policies and guidelines; supports compliance initiatives; maintains confidences; admits mistakes; conducts business with honesty, shows consistency in words and actions; follows through on commitments.

Job duties with at least occasional or possible access to: (1) patients, the general public, or other employees; (2) confidential protected health information and other confidential KP information (including employee, proprietary, financial or trade secret information); (3) KP property and assets, for example, electronic assets, medical instruments, or devices; (4) controlled substances regulated by federal law or potentially subject to diversion.

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