Remote Utilization Management Nurse Coordinator (RN/LVN)

Yoh, A Day & Zimmermann Company; Redding (CA); Hybrid; USD 6,199,000 - 7,577,000; Full time

Benefits offered by this job

Medical, Prescription, Dental & Vision

Health Savings Account

Life & Disability Insurance

MetLife Voluntary Benefits

Employee Assistance Program (EAP)

401K Retirement Savings Plan

Direct Deposit & weekly epayroll

Referral Bonus Programs

Certification and training

Job summary

Yoh, a Day & Zimmermann company, seeks an experienced Utilization Management Nurse Coordinator (RN or LVN) for a temp 6+ month remote contract based out of Redding or Fairfield, CA. Initial onsite training for 3 weeks, then transition to fully remote.

Responsibilities include reviewing outpatient authorizations, evaluating medical necessity, and ensuring CMS and health plan compliance. 3–5 years of clinical nursing experience preferred; Monday–Friday with one weekend per month.

Qualifications

• Active/unrestricted California RN or LVN license.
• Experience in Utilization Management, Prior Authorization, Case Management, or Managed Care.
• Familiarity with CMS, Medicare, Medicaid, and commercial health plan guidelines.
• High degree of independence, flexibility, initiative, and commitment.
• Solid critical thinking and problem-solving skills.
• Ability to work in a fast-paced, member-service oriented environment.

Responsibilities

• Review outpatient authorization requests using InterQual and clinical guidelines.
• Evaluate medical necessity, appropriateness of treatment, and benefit coverage requirements.
• Analyze clinical documentation submitted by providers and facilities.
• Approve services within RN authority levels and refer complex cases to Medical Directors as needed.
• Communicate with providers to obtain additional information for determinations.
• Ensure compliance with CMS, NCQA, DHCS, state and health plan regulations.
• Document review findings in the utilization management system.
• Meet turnaround time requirements for authorization decisions.
• Participate in quality improvement initiatives and audit activities.
• Collaborate with Case Management, Care Coordination, Disease Management, and Provider Relations teams.

Skills

CA RN/LVN license

Utilization Management

Prior Authorization

Case Management

Managed Care

CMS guidelines

Independence

Fast-paced environment

Critical thinking

Problem solving

Job description

Yoh, a Day & Zimmermann company, seeks an experienced Utilization Management Nurse Coordinator (RN or LVN) for a temp 6+ month remote contract based out of Redding or Fairfield, CA. Initial onsite training for 3 weeks, then transition to fully remote.

Responsibilities include reviewing outpatient authorizations, evaluating medical necessity, and ensuring CMS and health plan compliance. 3–5 years of clinical nursing experience preferred; Monday–Friday with one weekend per month.