You are applying for a position through Medix, a staffing agency. The actual posting represents a position at one of our clients.
Job Summary
Our client is seeking a self-motivated and clinical Utilization Review Nurse to join their Managed Care Organization. In this role, you will evaluate member care plans and requests for medical necessity, ensuring high-quality, cost-effective healthcare delivery. You will work cross-functionally with medical directors and clinical peers to conduct prospective, concurrent, and retrospective reviews for long-term care services and durable medical equipment.
Key Responsibilities
- Perform prospective, concurrent, and retrospective utilization reviews using evidence-based clinical criteria to determine medical necessity and coverage appropriateness.
- Partner directly with Physician Peer Reviewers and Medical Directors to review complex cases, support coverage decisions, and mitigate potential care delays or coverage denials.
- Intervene proactively in care planning to reduce administrative delays, address authorization issues, and ensure seamless delivery of long-term support services.
- Maintain complete, accurate, and timely documentation within the electronic health record system in accordance with regulatory standards and internal organizational policies.
- Follow up on denial outcomes and internal appeals in a timely manner while contributing to ongoing organizational Quality and Performance Improvement (QPI) initiatives.
Qualifications
- Active, unrestricted Registered Nurse (RN) license in good standing.
- Bachelor of Science in Nursing (BSN) from an accredited institution.
- Minimum of 2+ years of Utilization Review / Utilization Management experience within a Managed Care Organization (MCO) or Health Plan.
- Direct experience in Managed Long-Term Care (MLTC), including authorization workflows for Personal Care Aide (PCA) services, Durable Medical Equipment (DME), Personal Emergency Response Systems (PERS), and Social Adult Day Care (SADC).
- Strong working knowledge of Medicare and/or Medicaid coverage guidelines, benefit limitations, and state healthcare regulations.
Skills
- Proficiency in evidence-based clinical decision tools such as InterQual and Milliman Care Guidelines (MCG).
- Strong communication and teamwork skills.
Additional Requirements
This position offers 100% remote work flexibility.
Benefits
- Paid Sick Leave (Medix provides paid sick leave according to state and local sick leave ordinances).
- Health Benefits / Dental / Vision (Medix offers 6 different health plans: 3 Major Medical Plans, 2 Fixed Indemnity Plans (Standard and Preferred), and 1 Minimum Essential Coverage (MEC) Plan. Eligibility for health benefits is based on verifying that an average of 30 hours per week during the first 4 weeks of the work assignment has been met. If you meet eligibility requirements and take action to enroll, you will be covered no earlier than 60 days into your assignment, depending on plan selection(s)).
- 401k (Eligible on the first 401k open enrollment date following 6 consecutive months on assignment. 401k Open Enrollment dates are 1/1, 4/1, 7/1, and 10/1).
- Short Term Disability Insurance.
- Term Life Insurance Plan.
Required Employment / Compliance Language
This job description is intended to convey information essential to understanding the scope of the position and is not an exhaustive list of responsibilities or requirements. Other functions may be assigned, and management retains the right to add or change the duties of the position at any time.
*We will consider for employment all qualified Applicants, including those with criminal histories, in a manner consistent with the requirements of applicable federal, state, and local laws, including the City of Los Angeles' Fair Chance Initiative for Hiring Ordinance (FCIHO), Los Angeles Fair Chance Ordinance for Employers (ULAC), The San Francisco Fair Chance Ordinance (FCO), and the California Fair Chance Act (CFCA).
Medix Overview:
With over 20 years of experience connecting organizations with highly qualified professionals, Medix is a leading provider of workforce solutions for clients and candidates across the healthcare, scientific, technology, and government industries. Through our core purpose of positively impacting lives, we’re dedicated to creating opportunities for job seekers at some of the nation's top companies. As an award-winning career partner, Medix is committed to helping talent find fulfilling and meaningful work because our mission is to help you achieve yours.
Any required state or Joint Commission training is compensated at the state or local minimum wage rate.
*As a job position within our Care Management division, a successful completion of a background check may be required as a condition of employment. This requirement is directly related to essential job functions including but not limited to: accessing financial and confidential information, access and handling of patient medical records, providing medical care inside a patient’s residential address, driving, prescription and other drug access and administration, and working with vulnerable populations, such as, minors, elderly and those with physical or mental disabilities. Due to these job duties, this position has a significant impact on the business operations and reputation, as well as the safety and well-being of individuals who may be cared for as part of the job position or who may interact with staff or clients.
