Hybrid Utilization Nurse Auditor — Denials & Appeals

UCLA Health; Los Angeles (CA); Hybrid; USD 98,000 - 215,000; Full time

Job summary

UCLA Health is seeking an Utilization Management Nurse Auditor in Los Angeles to support clinical review, audit, and quality improvement across the health system.

The role conducts concurrent and retrospective reviews, supports appeals, analyzes utilization trends, and collaborates with Revenue Cycle, Care Coordination, and Physician Advisory teams to strengthen medical necessity determinations and payer compliance. Strong data skills and Epic proficiency are essential.

Qualifications

• Bachelor’s degree in Nursing or a related healthcare field.
• Five or more years of professional healthcare experience in a clinical, quality improvement, utilization management, or related setting.
• Three or more years of experience in utilization management, case management, and/or clinical auditing.
• Active, unrestricted Registered Nurse license in California.
• Thorough knowledge of utilization management criteria (InterQual/MCG) and payer requirements.

Responsibilities

• Review concurrent and retrospective denials to assess admission status, level of care, length of stay, and medical necessity.
• Prepare clinical summaries and documentation for first- and second-level appeals and collaborate on audit responses.
• Analyze denial and audit findings to identify trends and opportunities for improvement in utilization management.
• Evaluate cases using established criteria (InterQual/MCG) and elevate complex cases as needed.
• Collaborate with Physician Advisors and Care Coordination teams to improve documentation of medical necessity and status designation.
• Prepare reports, dashboards, and presentations for leadership and Utilization Management Committee.
• Support performance improvement initiatives targeting length of stay, denial rates, and data integrity.

Skills

Utilization management

Clinical auditing

Data analysis

Communication

Report writing

Cross-functional collaboration

Education

Bachelor’s degree in Nursing or related healthcare field

Tools

Epic

Job description

UCLA Health is seeking an Utilization Management Nurse Auditor in Los Angeles to support clinical review, audit, and quality improvement across the health system.

The role conducts concurrent and retrospective reviews, supports appeals, analyzes utilization trends, and collaborates with Revenue Cycle, Care Coordination, and Physician Advisory teams to strengthen medical necessity determinations and payer compliance. Strong data skills and Epic proficiency are essential.