Hybrid Remote Utilization Management RN — Optimize Care

Valley Children's Healthcare; Madera (CA); Hybrid; USD 90,000 - 130,000; Full time

Job summary

Valley Children's Healthcare in California seeks an experienced Utilization Management Nurse to support the Case Management Department by applying clinical criteria to admissions and payer requirements.

This hybrid, full-time role involves denial management, collaboration with physicians and payors, and providing staff with guidance on utilization management standards, while ensuring regulatory compliance and efficient resource use.

Qualifications

• Associate Degree in Nursing (required).
• California RN license (required).
• Minimum 3 years RN experience in an acute care hospital.
• Pediatric nursing and Case Management experience preferred.
• Knowledge of utilization management regulations and payer practices.

Responsibilities

• Perform daily screening of admissions against clinical criteria.
• Active involvement in denial management.
• Serve as clinical resource on utilization criteria for staff.
• Communicate with payors to address utilization concerns.
• Support compliance with regulatory and departmental requirements.

Skills

Clinical nursing expertise

Utilization management knowledge

Communication skills

Interprofessional collaboration

Prioritization & multitasking

Proficiency with office software

Education

Associate Degree in Nursing

Bachelor’s Degree in Nursing or related field

Job description

Valley Children's Healthcare in California seeks an experienced Utilization Management Nurse to support the Case Management Department by applying clinical criteria to admissions and payer requirements.

This hybrid, full-time role involves denial management, collaboration with physicians and payors, and providing staff with guidance on utilization management standards, while ensuring regulatory compliance and efficient resource use.