Remote Utilization Management Nurse, RN

Inland Empire Health Plan; United States; Remote; USD 91,000 - 121,000; Full time

Benefits offered by this job

Competitive salary

Telecommute schedule

On-site fitness center

Medical Insurance with Dental and Vis

Life, short-term, and long-term disab

Career advancement opportunities

Wellness programs

Flexible Spending Account

CalPERS retirement

457(b) option with a contribution

Pet care insurance

Job summary

Inland Empire Health Plan (IEHP) is seeking an experienced Utilization Management Nurse to perform prospective, concurrent and retrospective reviews ensuring medical necessity and alignment with UM criteria. Under the UM Manager, you will collaborate with Medical Directors and translate complex medical language into clear member communications.

This role supports quality objectives, LEAN initiatives, and denial language standardization while maintaining timeliness and accuracy in high-volume

Qualifications

• Active, unrestricted RN license issued by the California BRN required.
• Minimum 2 years of direct clinical patient care in an acute care setting.
• HMO/Managed Care experience preferred.

Responsibilities

• Conduct prospective, concurrent, and retrospective reviews for medical necessity.
• Screen information and authorizations against current UM criteria with Medical Directors.
• Review denials and letters to determine appropriateness and potential alternatives.
• Draft denial language and translate medical terms into lay language.
• Maintain standardized denial language matrices for internal/external use.

Skills

UM criteria knowledge

Communication skills

Critical thinking

Medical record abstraction

Documentation skills

Education

RN license (CA BRN)

Bachelor's degree in Nursing (preferred)

Job description

Inland Empire Health Plan (IEHP) is seeking an experienced Utilization Management Nurse to perform prospective, concurrent and retrospective reviews ensuring medical necessity and alignment with UM criteria. Under the UM Manager, you will collaborate with Medical Directors and translate complex medical language into clear member communications.

This role supports quality objectives, LEAN initiatives, and denial language standardization while maintaining timeliness and accuracy in high-volume