Clinical Review Nurse RN 3 -Prior Auth

Wollborg Michelson Personnel Service Inc; Rancho Cordova (CA); On-site; USD 90,000 - 110,000; Full time

Job summary

Wollborg Michelson Recruiting in California seeks an experienced Utilization Review Nurse to perform prospective reviews and initial determinations using clinical guidelines and ICD-10 alignment. The role requires five to seven years in nursing, an active RN license, and experience with prior authorization and PPO plans, delivering timely, compliant determinations and clear member/provider communications.

Join a team focused on quality care, regulatory compliance, and coordination with case

Qualifications

• Associate degree in nursing required; bachelor’s degree preferred.
• Active nursing license required.
• Five to seven years of nursing experience required.
• Experience with prior authorization and utilization review required.
• Experience with PPO health plans preferred.

Responsibilities

• Review and approve cases according to applicable clinical guidelines, policies, and regulatory requirements.
• Triage and prioritize cases to meet required turnaround times.
• Expedite reviews for members with urgent care needs.
• Develop determination recommendations and present potential denials to the Medical Director as required.
• Communicate determinations to providers and members in compliance with state, federal, and accreditation requirements.
• Prepare and review member-centered documentation and correspondence related to determinations.
• Identify potential quality-of-care issues, service delays, and treatment delays, and intervene when clinically appropriate.
• Identify potential third-party liability and coordination-of-benefits cases, and notify the appropriate departments.
• Provide referrals to case management and disease management programs.

Skills

Utilization review

Prior authorization

Clinical criteria

ICD-10 coding

Case triage

Regulatory compliance

Documentation

Professional communication

Education

Associate degree in nursing

Bachelor's degree preferred

Job description

Utilization Review Nurse

Job Summary: Performs prospective reviews and initial determination approvals using evidence-based guidelines, organizational policies, and nationally recognized clinical criteria. Ensures diagnoses align with ICD-10 codes and supports timely access to appropriate care.

Responsibilities

• Review and approve cases according to applicable clinical guidelines, policies, and regulatory requirements.
• Triage and prioritize cases to meet required turnaround times.
• Expedite reviews for members with urgent care needs.
• Develop determination recommendations and present potential denials to the Medical Director as required.
• Communicate determinations to providers and members in compliance with state, federal, and accreditation requirements.
• Prepare and review member-centered documentation and correspondence related to determinations.
• Identify potential quality-of-care issues, service delays, and treatment delays, and intervene when clinically appropriate.
• Identify potential third-party liability and coordination-of-benefits cases, and notify the appropriate departments.
• Provide referrals to case management and disease management programs.

Requirements

• Associate degree in nursing required;bachelor's degree preferred.
• Active nursing license required.
• Five to seven years of nursing experience required.
• Experience with prior authorization and utilization review required.
• Experience with PPO health plans preferred.

Skill

• Utilization review and prior authorization
• Clinical criteria and evidence-based guidelines
• ICD-10 coding and diagnosis verification
• Case triage and prioritization
• Regulatory and accreditation compliance
• Clinical documentation and professional communication

Summary Qualification

• Licensed nurse with an associate degree or higher in nursing.
• Five to seven years of relevant nursing experience.
• Knowledge of utilization management, prior authorization, and PPO health plans.
• Ability to make clinically sound determinations and identify care coordination needs.
• Strong communication, documentation, and case management skills.

Equal Opportunity Employer

Wollborg Michelson Recruiting is an Equal Opportunity Employer and prohibits discrimination of any kind. We ensure job offers are made based of one s employment experience, skills, and qualifications, regardless of race, gender, ethnic origin, or any other classification protected by law.

All applicants must furnish proper identification to prove their legal right to work in the US upon a job offer. We participate in E-Verify to confirm one s right to work in the US. Wollborg Michelson Recruiting does not provide sponsorship for an employment-based visa status.