RN Utilization Management Nurse (NICU / Peds) – California (JR169694)
Job Summary: This virtual role supports complex high‑care utilization management for NICU and pediatric populations, providing clinical judgment and critical thinking to assess member medical necessity. The position involves coordination with providers, nursing teams, and medical directors to ensure appropriate care delivery.
Responsibilities
Analyze member clinical information and apply nursing judgment and evidence‑based guidelines to determine medical necessity.
Collaborate with healthcare providers to promote quality member outcomes, optimize benefits, and support effective resource use.
Detect and assess abnormalities in complex clinical concepts to provide recommendations for appropriate care levels.
Consult with Medical Director on unclear or complex cases.
Recommend alternate appropriate care types, places, or levels as needed.
Coordinate discharge planning with case‑management nurses ensuring safe patient transition.
Support lower‑level nurses by sharing expertise and training.
Participate in cross‑functional teams, projects, and process‑improvement activities.
Provide quality audit and corrective action planning assistance.
Qualifications
Associate’s degree in nursing (or higher).
Minimum 4 years of care or case management experience and 2 years of clinical utilization review or managed care experience (or equivalent).
Current active, valid and unrestricted RN license in California.
Preferred Qualifications
Strong clinical experience in NICU or Pediatrics.
Utilization management/review experience in managed care or hospital settings.
Experience with MCG.
Benefits
Comprehensive benefits including health, dental, vision, short and long term disability, 401(k) with company match, stock purchase plan, paid time off and incentive bonus programs. Additional benefits such as equity stock purchase and wellness programs are also available.
Location & Salary
California (remote work; hybrid in‑person training required). 8‑hour shift (8 am – 6 pm PST), rotating weekends and holidays. Salary range: $41.38 to $67.72 per hour (converted to yearly range). Overtime pay applies under California law for eligible employees.
Equal Opportunity Employer
Elevance Health is an Equal Employment Opportunity Employer. All qualified applicants will receive consideration for employment without regard to age, citizenship status, color, creed, disability, ethnicity, genetic information, gender identity, marital status, national origin, race, religion, sex, sexual orientation, veteran status, or any other status protected by applicable law. Applicants requiring accommodations may contact elevancehealthjobssupport@elevancehealth.com.