PACE UTILIZATION REVIEW SPECIALIST - RN

Position Summary

The PACE Utilization Review Specialist – RN oversees clinical utilization management for participants enrolled in the Program for All-Inclusive Care for the Elderly. The position ensures that services are medically appropriate, cost-effective, and coordinated. This role works closely with the PACE Medical Director and interdisciplinary team to review clinical cases, manage utilization policies, and ensure regulatory compliance.

Essential Duties and Responsibilities

• Conduct concurrent and retrospective utilization reviews for acute, post-acute, and outpatient services.
• Review clinical documentation and determine appropriate levels of care based on evidence-based criteria.
• Manage inpatient and post-acute length of stay and coordinate timely discharge planning.
• Review, develop, and implement utilization management policies and workflows.
• Prepare and present clinical case summaries and recommendations to internal leadership.
• Serve as a resource for primary care providers and care managers on utilization and authorization requirements.
• Ensure appropriate service authorization for hospitalizations, referrals, and specialty services.
• Communicate with providers, payers, and internal teams regarding claim adjudication and payment status.
• Identify high-risk participants and coordinate with clinical leadership on care strategies.
• Track and report utilization metrics and trends to support program improvement.
• Oversee denial management processes and provider appeal reviews.
• Document all utilization management activities in the electronic medical record.
• Participate in interdisciplinary team meetings and care planning sessions.
• Support staff education and training on utilization management policies and standards.

Minimum Qualifications

• Graduate of an accredited school of nursing with a current unencumbered Registered Nurse license in the State of California.
• Current BLS certification from the American Heart Association.
• Valid California driver’s license and acceptable driving record.
• Minimum three years of managed care experience, including one year in utilization management, case management, or care coordination.
• Minimum one year of experience working with the frail or elderly population.
• Strong analytical skills with the ability to evaluate clinical documentation and apply evidence-based criteria.
• Knowledge of State and Federal healthcare regulations, quality standards, and utilization review principles and guidelines such as Medicare, Medicaid and MCG/InterQual.
• Proficient in Microsoft Office, including advanced Excel skills.
• Excellent communication skills, both written and verbal.
• Demonstrated ability to work collaboratively across multidisciplinary teams.

Preferred Qualifications

• Bachelor of Science in Nursing (BSN) strongly preferred.
• Certified Case Manager (CCM) or Certified Professional in Healthcare Management (CPHM) preferred.

Physical Demands and Work Environment

• Requires standing, walking, occasional pushing, pulling, and lifting.
• Ability to lift up to 30 pounds; assistance required for heavier loads.
• Manual dexterity and visual/hearing acuity required for clinical assessment and documentation.
• Exposure to infectious materials and biohazards common in healthcare settings.
• Must be able to communicate with participants, caregivers, and team members, including those with cognitive or physical limitations.
• Moderate stress related to deadlines, caseload volume, and patient conditions.

Direct Reports

PACE Medical Director