RN Utilization Review & Quality Improvement Specialist

cvhp; Covina (CA); On-site; USD 7,164,000 - 11,159,000; Full time

Job summary

Emanate Health in Covina, CA, seeks a Utilization Review Nurse to evaluate medical records and determine medical necessity using policies and guidelines for urgent and standard reviews. You will document decisions and support claims reviews, applying clinical judgment throughout the process.

California RN license required; minimum three years' utilization management experience; strong customer service skills. Deliver world-class health care one patient at a time.

Qualifications

• Three years of utilization management experience.
• Excellent customer service skills.

Responsibilities

• Evaluate medical records to determine medical necessity using policies and guidelines for urgent and standard reviews.
• Document decisions using indicated protocol sets or clinical guidelines and support medical claims and utilization practices.
• Complete medical necessity and level of care reviews and refer to Medical Directors when needed.

Skills

Utilization management

Job description

Emanate Health in Covina, CA, seeks a Utilization Review Nurse to evaluate medical records and determine medical necessity using policies and guidelines for urgent and standard reviews. You will document decisions and support claims reviews, applying clinical judgment throughout the process.

California RN license required; minimum three years' utilization management experience; strong customer service skills. Deliver world-class health care one patient at a time.