Utilization Management RN

Utilization Management RN

Location: Santa Barbara, CA (Remote Eligible)

Classification: Exempt

Compensation: $95,000–$138,000 annually, depending on experience

Overview:

Our client is seeking an experienced Registered Nurse to join their Dual Special Needs Program (D-SNP) team. This position ensures members receive timely, medically necessary, and cost-effective care through clinical review, care coordination, and collaboration with internal and external partners. The ideal candidate has a strong clinical background, experience with utilization management, and a commitment to improving outcomes for dual-eligible members.

Responsibilities:

• Conduct clinical reviews and prior authorization determinations for inpatient, outpatient, and ancillary services using evidence-based criteria.
• Complete concurrent and retrospective reviews to ensure medical necessity and regulatory compliance.
• Coordinate with physicians, interdisciplinary teams, and providers to support integrated, member-centered care.
• Participate in care transition planning and interdisciplinary rounds to improve continuity of care and reduce avoidable hospitalizations.
• Manage denials, appeals, and regulatory notifications while maintaining thorough documentation in the care-management system.
• Apply Medicare and Medi-Cal guidelines, ensuring adherence to federal, state, and internal compliance standards.
• Support education efforts for providers and staff on coverage determinations and process improvements.

Qualifications:

• Current, active, unrestricted California RN or NP license required.
• Minimum 3 years of clinical nursing experience (acute care, case management, or utilization management preferred).
• At least 2 years of experience in a managed care or health-plan setting.
• Working knowledge of Medicare Advantage, Medi-Cal, and evidence-based criteria (e.g., MCG).
• Excellent communication, documentation, and problem-solving skills.
• Strong attention to detail, time management, and ability to prioritize in a fast-paced environment.
• Proficiency with EMR and utilization-management systems.

Preferred:

• Bachelor of Science in Nursing (BSN).
• Certification in case management, utilization, or quality management (CCM, CPHQ, CPUR, etc.).

Location & Work Environment:

This position can be remote, with occasional in-person meetings. Regular business hours apply, with potential for limited on-call participation.