Remote Utilization Management RN Coordinator

Yoh,-A-Day-; Fairfield (CA); Hybrid; USD 63,000 - 89,000; Full time

Benefits offered by this job

Medical benefits

Dental benefits

Vision benefits

HSA

Life & Disability Insurance

401K Retirement Savings Plan

Direct Deposit & weekly pay

Job summary

Yoh, a Day & Zimmermann company, is seeking an Utilization Management Nurse Coordinator (RN) for a remote contract opportunity based in Fairfield/Redding, CA. Training is onsite for 3 weeks, then remote with regular weekday hours and one weekend per month.

The role emphasizes reviewing outpatient authorizations, assessing medical necessity, and ensuring compliance with CMS/NCQA guidelines while coordinating with interdisciplinary teams.

Qualifications

• Active/unrestricted Registered Nurse license in California.
• Experience in Utilization Management, Prior Authorization, Case Management, or Managed Care.
• Familiarity with CMS, Medicare, Medicaid, and commercial health plan guidelines.
• 3–5 years of clinical nursing experience.
• Experience reviewing outpatient authorizations and medical necessity determinations.

Responsibilities

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

Skills

RN license (CA)

Utilization Management

Prior Authorization

Case Management

Managed Care

CMS/Medicare knowledge

Tools

InterQual

Job description

Yoh, a Day & Zimmermann company, is seeking an Utilization Management Nurse Coordinator (RN) for a remote contract opportunity based in Fairfield/Redding, CA. Training is onsite for 3 weeks, then remote with regular weekday hours and one weekend per month.

The role emphasizes reviewing outpatient authorizations, assessing medical necessity, and ensuring compliance with CMS/NCQA guidelines while coordinating with interdisciplinary teams.