$65.53 - $84.75 hourly; not specified; not specifi...
On-site
Clinical reviews of prior authorization requests
Apply clinical guidelines in review decisions
Communicate with providers for clarification
The UM Review Nurse applies clinical judgment, regulatory standards, and established guidelines to determine medical necessity and benefit eligibility for prior authorization requests
Job Summary
The UM Review Nurse applies clinical judgment, regulatory standards, and established guidelines to determine medical necessity and benefit eligibility for prior authorization requests.
Key responsibilities include conducting clinical reviews, applying protocols and guidelines, coordinating escalations, and communicating with providers.
This role ensures compliance with CMS, state, federal, and UCLA Health standards while documenting findings and identifying process improvement opportunities.
Matching Summary
The UM Review Nurse applies clinical judgment, regulatory standards, and established guidelines to determine medical necessity and benefit eligibility for prior authorization requests.
Salary
$65.53 - $84.75 Hourly; Not specified; Not specified
Skills & Requirements
Must-have
Clinical reviews of prior authorization requests
Apply clinical guidelines in review decisions
Communicate with providers for clarification
Ensure compliance with standards
Review and validate cases
Document review findings in system
Nice-to-have
Resourcefulness and diplomacy
Self-directed and assertive problem-solving
Critical thinking and knowledge application
Collaborate with interdisciplinary teams
Identify process improvement opportunities
Key Requirements
BSN and/or MSN required
Current California RN license required
Three years of experience in utilization management preferred
Team leading or management experience preferred
Proficient computer skills including Microsoft Word, Excel, and Managed Care software