RN Utilization Management Specialist

HJSRLLC; Long Beach (CA); On-site; USD 90,000 - 120,000; Full time

Job summary

HJSRLLC is seeking a Registered Nurse (RN) to join our Utilization Management team in Long Beach, CA. You will conduct concurrent reviews, prior authorizations, and medical necessity assessments to ensure cost-effective, evidence-based care for members.

This role requires collaboration with physicians, hospitals, and interdisciplinary teams in a dynamic managed care setting. The ideal candidate has at least 4 years of clinical nursing experience and a background in managed care, with proficiency

Qualifications

• Active RN license required.
• Graduate of an accredited School of Nursing.
• Minimum 4 years of clinical nursing experience.
• Minimum 2 years of managed care experience (Medicare Advantage experience required).
• Direct experience in concurrent review, inpatient utilization management, discharge planning, and transitions of care.

Responsibilities

• Perform concurrent, prior authorization, and retrospective utilization reviews.
• Evaluate medical necessity using InterQual, MCG, CMS guidelines.
• Coordinate discharge planning and transitions of care with providers and facilities.
• Collaborate with physicians, hospital staff, specialists, and internal care management teams.
• Request and review additional clinical documentation as needed; elevate complex cases to Medical Director.
• Educate providers on utilization management policies and review criteria.
• Document all reviews and decisions within medical management systems; identify care gaps and support quality improvement initiatives.

Skills

RN licensure

Clinical nursing

Managed care

InterQual CMS guidelines

Medical management software

MS Office

Strong communication

Education

BSN (preferred)

Tools

Medical management software

Microsoft Office

Job description

HJSRLLC is seeking a Registered Nurse (RN) to join our Utilization Management team in Long Beach, CA. You will conduct concurrent reviews, prior authorizations, and medical necessity assessments to ensure cost-effective, evidence-based care for members.

This role requires collaboration with physicians, hospitals, and interdisciplinary teams in a dynamic managed care setting. The ideal candidate has at least 4 years of clinical nursing experience and a background in managed care, with proficiency