Registered Nurse - Utilization Management

Responsibilities

• Review, process, and document requests for services, referrals, equipment, and other participant care needs based on medical necessity criteria, Medicare/Medicaid guidelines, and PACE requirements.
• Conduct concurrent and retrospective utilization reviews for inpatient, outpatient, specialty care, skilled nursing facility, and ancillary services.
• Monitor hospitalizations, skilled nursing facility stays, and transitions of care to support safe, timely, and appropriate discharge planning.
• Collaborate with the Interdisciplinary Team to ensure utilization management decisions align with individualized participant care plans, clinical needs, and participant-centered goals.
• Communicate utilization management decisions to providers, participants, caregivers, and internal team members in accordance with regulatory and organizational timeframes.
• Serve as a liaison with contracted providers, hospitals, skilled nursing facilities, and ancillary vendors to support efficient, coordinated, and participant-centered care delivery.
• Identify service requests requiring physician or Medical Director review and escalate appropriately for clinical determination.
• Maintain accurate, timely, and audit-ready documentation of utilization management activities in the electronic medical record and health plan systems.
• Support compliance with CMS, DHCS, Medicare, Medicaid, and PACE requirements, including participation in audits, quality assurance activities, compliance reviews, and process improvement efforts.
• Contribute to the development, refinement, and implementation of utilization management policies, procedures, workflows, documentation standards, and staff/provider education.

Qualifications & Experience

• Active, unrestricted RN license in the state of practice.
• Minimum of three (3) years of nursing experience, preferably in geriatrics, acute care, case management, utilization management, or a related clinical setting.
• Strong understanding of Medicare/Medicaid coverage criteria, managed care principles, medical necessity review, and applicable PACE program requirements.
• Demonstrated passion and mission alignment for serving high-risk seniors, frail older adults, and medically complex populations.
• Strong critical thinking, clinical judgment, problem-solving, and decision-making skills.
• Ability to work effectively in a collaborative, participant-centered environment while maintaining regulatory, compliance, and documentation standards.
• Exceptional communication and interpersonal skills, with the ability to coordinate across providers, facilities, vendors, participants, caregivers, and internal teams.
• Proficiency with electronic medical record systems, utilization management platforms, and related digital workflows.
• Ability to work independently, manage multiple priorities, and appropriately escalate issues with minimal supervision.
• Experience working in a health plan, PACE organization, managed care environment, or value-based care model.
• CCM, CPUR, CPHM, or other relevant case management or utilization review certification.