Remote Utilization Management Nurse – RN/LVN

Location: 100% Remote
Schedule: Monday–Friday, 8:00 AM–5:00 PM PST
Pay: $40–$51/hour, depending on experience and licensure

Position Overview

We are seeking an experienced Utilization Management (UM) Nurse to manage the end-to-end utilization management process, including inpatient review, concurrent review, and discharge planning.

The ideal candidate has strong experience in MCG criteria, Medicare Advantage, inpatient/SNF utilization management, and complex discharge planning. This is a fast-paced, metrics-driven environment requiring strong clinical judgment, attention to detail, and confidence communicating with physicians and Medical Directors.

Responsibilities

• Manage the full Utilization Management process from initial review through discharge planning.
• Conduct daily inpatient and concurrent reviews and coordinate appropriate levels of care.
• Coordinate care and placements for:
  • Durable Medical Equipment (DME)
  • Home Health (HH)
  • Skilled Nursing Facilities (SNF)
• Utilize MCG criteria to complete clinical reviews and determine medical necessity.
• Write clear, formal clinical denial letters when criteria are not met.
• Apply LCD/NCD guidelines when completing pre-service authorizations and determining appropriate clinical tiers.
• Apply CMS guidelines when reviewing SNF and ARU cases.
• Communicate effectively with Medical Directors, physicians, hospitals, and other clinical partners.
• Present clear and concise clinical case summaries during daily multidisciplinary rounds.
• Manage a high daily caseload while meeting strict quality and compliance standards.

Required Qualifications

• Active, unencumbered California RN or LVN license.
• Direct experience working in an IPA, MSO, delegated model, or health plan environment.
• Hands-on experience using MCG criteria for inpatient acute and/or SNF utilization reviews.
• Experience with:
  • Inpatient initial and concurrent review
  • SNF initial, concurrent, and discharge review
  • Complex discharge planning
  • Clinical denial letters
  • Medicare guidelines for SNF and ARU
  • CMS SNF criteria
  • NCD and LCD guidelines
  • Home Health criteria
  • QIO, NOMNC, and DENC processes
• Proficiency with Microsoft Word, Excel, PDFs, and standard digital workspace tools.
• Strong written and verbal communication skills.
• Ability to confidently communicate with physicians and Medical Directors.

Preferred Qualifications

• Strong Medicare Advantage experience.
• Commercial Utilization Management experience.
• Experience working within strict CMS turnaround requirements.
• Strong understanding of observation vs. inpatient criteria.
• 5+ years of concurrent inpatient Utilization Management experience preferred.
• Experience working in a fast-paced, high-volume UM environment.

Schedule

• Monday–Friday, 8:00 AM–5:00 PM PST
• 1-hour lunch plus morning and afternoon breaks.
• Must maintain California PST hours  

^*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).

^*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.