Remote RN: Utilization Management Nurse

Inland Empire Health Plan; California; Remote; USD 85,000 - 110,000; Full time

Benefits offered by this job

Competitive salary

Telecommute schedule

State of the art fitness center on‑sit

Medical Insurance with Dental and Vis

Life, short‑term, and long‑term)

Career advancement opportunities and p

Wellness programs that promote a work‑

Flexible Spending Account – HealthCare

CalPERS retirement

457(b) option with a contribution matc

Paid life insurance for employees

Pet care insurance

Job summary

IEHP is seeking an experienced Utilization Management Nurse in California to lead prospective, concurrent and retrospective reviews of referrals, ensuring regulatory compliance and clear member correspondence.

Under the guidance of the UM Manager, you will apply nationally recognized UM criteria, assess medical necessity, and collaborate with physicians and care teams to meet members' needs while supporting IEHP's commitment to quality and patient-centered care.

Qualifications

• Two years direct clinical patient care in an acute care setting with an active RN license.
• Experience in an HMO or Managed Care setting preferred.
• California RN license active and unencumbered is required.
• Bachelor’s degree in Nursing preferred.

Responsibilities

• Prospectively, concurrently, and retrospectively review referrals to ensure regulatory requirements are met.
• Ensure member correspondence uses appropriate UM criteria and clear language.
• Apply nationally recognized UM criteria to determine medical necessity and benefits.
• Communicate findings and recommendations to physicians and care teams to support patient care.

Skills

UM criteria knowledge

Nursing practice

Medical terminology

Regulatory compliance

Communication skills

Caseload management

Analytical thinking

Education

RN license

Bachelor’s degree in Nursing

Job description

IEHP is seeking an experienced Utilization Management Nurse in California to lead prospective, concurrent and retrospective reviews of referrals, ensuring regulatory compliance and clear member correspondence.

Under the guidance of the UM Manager, you will apply nationally recognized UM criteria, assess medical necessity, and collaborate with physicians and care teams to meet members' needs while supporting IEHP's commitment to quality and patient-centered care.