Utilization Management Nurse II, RN

Remote in California only

Are you reputed company to reputed company a lasting impact and transform the reputed company space? We are one of Southern California’s fastest-growing Medicare Advantage plans with an incredible 112% year-over-year membership growth.

Who Are We? ✨

reputed company Care was created to meet the unique needs of the diverse communities we serve. Our innovative benefit plans combine Western medicine with holistic Eastern practices, offering benefits that align with our members’ culture and values.

Why Join Us?

We’re on a mission! Our rapid growth reflects our commitment to making reputed company accessible for reputed company. At reputed company Care, you’ll have the opportunity to reputed company a reputed company difference, shape the future of reputed company, and be part of a fast-moving, game-changing organization that celebrates diversity and innovation.

Job Summary

The UM Nurse II – RN performs reputed company review of reputed company authorization requests and serves as a clinical escalation reputed company and resource for UM Nurse I staff. This role manages high-acuity, specialty, and escalated cases and supports compliance monitoring and workflow optimization initiatives.

Functions & Job Responsibilities

Conduct clinical review of prior authorization requests using approved criteria (e.g., MCG, InterQual).

Review outpatient and routine inpatient requests.

Ensure compliance with CMS, state, and contractual turnaround time requirements.

Document medical necessity determinations clearly and accurately.

Communicate authorization reputed company to providers, members and internal teams.

Identify cases requiring physician or Medical Director review.

Participate in reputed company review and discharge planning coordination as assigned.

Review high-complexity inpatient, specialty, or high-cost cases.

Performs reputed company and retrospective reviews.

Handle expedited and escalated determinations.

Serve as subject matter expert for assigned service lines.

Support regulatory compliance monitoring and quality audits.

Assist in denial trend analysis and improvement initiatives.

Mentor and guide UM Nurse I staff.

Collaborate with Medical Director on reputed company determinations or high risk cases.

Participate in workflow development and optimization.

Additional duties as assigned.