Utilization Management Nurse

Overview

Our client, a provider of Health, Dental, Vision, Medicaid and Medicare Healthcare service plans in the state of California with 4.7 million members and $22.9 billion of annual revenues, seeks an accomplished Utilization Management Nurse

Position: Utilization Management Nurse

Location: REMOTE in CA

Duration: 6+ Month Contract with possible extension

Pay Rate: $50/hr - $55/hr (depending on experience)

Schedule: 8am – 5pm Pacific

Relocation Expenses/ Assistance: NO

Position Summary

The Utilization Management Nurse supports the Utilization Management (UM) team in reviewing inpatient stays for members to ensure appropriate levels of care based on nationally recognized clinical guidelines. Reporting to the Utilization Management Nurse Manager, this role is responsible for assessing medical necessity, coordinating discharge planning, and facilitating transitions to higher levels of care or out-of-network facilities as needed.

Key Responsibilities

• Perform prospective, concurrent, and retrospective utilization reviews and make first-level determination approvals using BSC and CMS evidence-based guidelines and nationally recognized criteria for the Medicare line of business.
• Conduct clinical reviews of claims to verify medical necessity, coding accuracy, and compliance with medical policy and contract requirements.
• Ensure discharge planning at appropriate levels of care, identifying post-acute needs such as DME, rehabilitation, or home health services to ensure quality, cost-effective transitions.
• Prepare and present cases to the Medical Director for oversight and determination, communicating results to providers and/or members per state, federal, and accreditation requirements.
• Develop and maintain member-centered documentation and correspondence reflecting determinations in compliance with regulatory and accreditation standards.
• Identify and escalate potential quality of care issues or treatment delays, intervening when clinically appropriate.
• Refer members to Case Management for ongoing support when acute inpatient needs impact discharge plans.
• Participate in staff meetings, clinical rounds, and weekly huddles.
• Maintain productivity and quality standards for all casework.
• Serve as a mentor or support resource for new employees.
• Maintain a HIPAA-compliant workspace in a telework environment.

Required Qualifications

• Associate’s degree in Nursing (Bachelor’s degree preferred)
• Active and unrestricted California RN license
• Minimum 5 years of clinical experience providing direct patient care
• Strong communication, critical thinking, and computer navigation skills

Preferred Qualifications

• Utilization Management experience with knowledge of MCG Criteria
• Background in Emergency Room and/or ICU nursing
• Experience with Medicare utilization review processes

Recruiter Contact Info

Sajag Bhardwaj

sajag.bhardwaj@ameritconsulting.com

www.ameritconsulting.com

I'd love to talk to you if you think this position is right up your alley, and assure prompt communication, whichever direction. If you're looking for rewarding employment and a company that puts its employees first, we'd like to work with you.

Company Overview:

Amerit Consulting is an extremely fast-growing staffing and consulting firm. Amerit Consulting was founded in 2002 to provide consulting, temporary staffing, direct hire, and payrolling services to Fortune 500 companies nationally; as well as small to mid-sized organizations on a local & regional level. Currently, Amerit has over 2,000 employees in 47 states. We develop and implement solutions that help our clients operate more efficiently, deliver greater customer satisfaction, and see a positive impact on their bottom line. We create value by bringing together the right people to achieve results. Our clients and employees say they choose to work with Amerit because of how we work with them - with service that exceeds their expectations and a personal commitment to their success. Our deep expertise in human capital management has fueled our expansion into direct hire placements, temporary staffing, contract placements, and additional staffing and consulting services that propel our clients’ businesses forward.

Amerit Consulting provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.

This policy applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation and training. Applicants, with criminal histories, are considered in a manner that is consistent with local, state and federal laws.