RN: Utilization, Quality & Peer Review Lead

careers-centralhealth; Los Angeles (CA); On-site; USD 90,000 - 120,000; Full time

Job summary

careers-centralhealth seeks a Clinical Quality and Utilization Review Specialist to oversee utilization management and peer review. You will coordinate reviews, ensure medical necessity, and lead quality improvement initiatives across inpatient and outpatient settings, collaborating with physicians, APPs, and interdisciplinary teams.

The role also involves preparing reports, directing RCA activities, and ensuring compliance with bylaws, policies, and accreditation standards.

Qualifications

• Bachelor's degree in nursing and active RN license in Texas or eligible.
• Two+ years in utilization management or case management in managed care or health system.
• Experience in peer review, quality improvement, or patient safety initiatives in last 5 years.

Responsibilities

• Coordinate and facilitate peer review activities.
• Support utilization management including reviews and authorizations.
• Collaborate with physicians, APPs, and care teams to ensure patient‑centered care.
• Prepare reports, dashboards, and presentations on utilization and quality outcomes.
• Provide education and coaching on quality improvement principles.

Skills

Clinical judgment

Utilization management

Peer review knowledge

Communication skills

Confidentiality

EHR proficiency

Quality improvement

Education

BSN or higher (RN) required

Advanced Practice Provider degree

Tools

EHR systems

Microsoft Office

Job description

careers-centralhealth seeks a Clinical Quality and Utilization Review Specialist to oversee utilization management and peer review. You will coordinate reviews, ensure medical necessity, and lead quality improvement initiatives across inpatient and outpatient settings, collaborating with physicians, APPs, and interdisciplinary teams.

The role also involves preparing reports, directing RCA activities, and ensuring compliance with bylaws, policies, and accreditation standards.