Clinical Resources Nurse

Western Health Advantage 📍 Sacramento, CA (Hybrid) 💲 Salary: $95,000–$115,000 annually "Our purpose is strong, our impact is lasting, join us on the journey" Western Health Advantage Summary Description Western Health Advantage is seeking a knowledgeable and collaborative Clinical Resources Nurse (CRN) to support Utilization Management activities at the corporate health plan level. Reporting to the Utilization Operations Director, the CRN partners closely with WHA’s Chief Medical Officer, Assistant Medical Director, Clinical Pharmacists, and operational teams to promote timely access to medically necessary, high-quality care. This position supports complex utilization reviews, out-of-area care, transitions and continuity of care, benefit interpretation, delegation oversight, and regulatory compliance. The CRN also works directly with contracted IPAs and medical groups to coordinate care, resolve clinical and benefit-related questions, and support the needs of WHA members. What You’ll Do Research, evaluate, and prepare complex cases involving new medical technologies, experimental treatments, organ transplants, cancer clinical trials, second opinions, and other specialized servicesReview pre-service requests for which WHA holds financial risk, confirming eligibility, medical necessity, and access to contracted providersCoordinate letters of agreement when medically necessary services are not available through contracted providersPerform telephonic concurrent reviews for members admitted through emergency departments to out-of-area hospitalsCollaborate with hospital discharge planners and medical group clinical teams to support appropriate transfers, safe discharges, and in-network follow-up careScreen and coordinate Continuity of Care requests for eligible members experiencing provider or medical group transitionsPrepare cases for review by the Chief Medical Officer or Assistant Medical Director and ensure timely follow-up, including authorization, approval, and denial notificationsAssist Member Services representatives and medical group Utilization Management teams with benefit interpretation, eligibility requirements, and regulatory compliance questionsProvide direction and clinical guidance to Intake Coordinators and collaborate with the Clinical Resources Intake SupervisorMaintain and update clinical reference materials, including WHA’s Prior Authorization and Durable Medical Equipment Benefit MatrixSupport DMHC regulatory reviews, NCQA accreditation audits, delegation oversight audits, and clinical chart abstractionsServe as a clinical liaison and resource for assigned medical groups and delegated entitiesCoordinate with Quality Management staff to screen cases identified as potential quality issuesInitiate and follow up on referrals for Case Management, Disease Management, and Behavioral Health servicesProvide care coordination, education, and support for members receiving transgender surgical servicesSupport WHA’s sales, marketing, and wellness activities by developing or reviewing clinical materials, presentations, and educational programsAssist with the development of educational resources related to health plan benefits and Utilization and Case Management processesComplete additional duties and special projects as assigned What You’ll Bring Bachelor’s degree in NursingActive California Registered Nurse (RN) or Licensed Vocational Nurse (LVN) license, maintained throughout employmentAt least three years of clinical experienceAt least one year of experience in utilization management, case management, discharge planning, or a managed care environmentStrong knowledge of care coordination, utilization review, benefit interpretation, and managed care operationsAbility to evaluate complex clinical information and collaborate effectively with physicians, pharmacists, nurses, operational teams, and delegated medical groupsIntermediate computer skills, including email, databases, word processing, spreadsheets, and presentation or graphics applicationsProficiency in creating formulas and graphs in Microsoft Excel and incorporating them into Word documentsAbility to speak, read, write, and understand the primary language used in the workplaceUtilization Management, Quality Management, or Certified Case Manager certification is preferred but not required Equal Employment Opportunity Western Health Advantage is committed to providing equal employment opportunities to employees and applicants based on merit and without regard to race, color, religion, gender, sexual orientation, gender identity or expression, national origin, age, physical or mental disability, medical condition, genetic information, marital status, ancestry, military or veteran status, or any other basis protected by federal or state law. Western Health Advantage values and supports the unique talents and strengths each employee brings to our organization. Collaborating with the best and brightest creates a dynamic and fulfilling work experience for our employees—and excellent service for our members. Western Health Advantage is an Equal Opportunity Employer. Applicant Safety Notice: Please be aware of phishing scams that solicit interviews or promote fraudulent work-from-home opportunities while posing as legitimate employers. Western Health Advantage will never request credit card information, send you a check, or ask you to make any payment as part of the employment process. Suspected scams may be reported to the Federal Trade Commission at ReportFraud.ftc.gov. Powered by JazzHR Ou5cnukdvK