Registered Nurse III (Utilization Review) 6+ Months Remote in California
Work Schedule: 8:00 AM PST – 5:00 PM PST (40 hours per week)
Day-to-Day Responsibilities
Conduct prospective, concurrent, and retrospective utilization reviews and first-level determination approvals for Medicare members using client's and CMS evidence-based guidelines, policies, and nationally recognized clinical criteria.
Evaluate members’ clinical needs and acuity to support appropriate discharge planning, including durable medical equipment and post-service requirements.
Prepare and present cases to the Medical Director for clinical oversight and medical-necessity determinations.
Communicate utilization determinations to providers and members in accordance with applicable state, federal, and accreditation requirements.
Develop and review member-centered documentation and correspondence to ensure accuracy and regulatory compliance.
Identify potential quality-of-care concerns, service delays, and treatment delays, and intervene as clinically appropriate.
Refer members to Case Management when acute inpatient needs may impact discharge planning.
Participate in staff meetings, clinical rounds, and weekly team huddles.
Maintain required quality and productivity metrics for assigned casework.
Maintain a HIPAA-compliant remote work environment.
Required Qualifications
Minimum 2 years of Utilization Management experience.
Minimum 5 years of direct patient-care experience in a hospital inpatient setting.
Strong communication, clinical judgment, and critical-thinking skills.
Associate Degree in Nursing (ADN) required; Bachelor’s degree preferred.
Preferred Qualifications
Emergency Room (ER) and/or Intensive Care Unit (ICU) experience.
Experience with MCG clinical guidelines.
Experience managing Medicare cases.
Technical Skills
Microsoft Windows
Microsoft Excel
Microsoft Outlook
Microsoft Teams
Resume Considerations
Insufficient clinical experience.
Multiple short-term positions without an explanation.
Applicant Notices & Disclaimers
For information on benefits, equal opportunity employment, and location-specific applicant notices, click here
At SPECTRAFORCE, we are committed to maintaining a workplace that ensures fair compensation and wage transparency in adherence with all applicable state and local laws. This position's pay range is $45.00/hr - $49.00/hr.
