RN Utilization Review Specialist

CommonSpirit Health; Long Beach (CA); On-site; USD 110,000 - 140,000; Full time

Job summary

CommonSpirit Health's St. Mary Medical Center in Long Beach, CA, seeks a Utilization Review Nurse to safeguard clinical decision-making, regulatory compliance, and efficient resource use.

You will review medical records, authorize services, and prepare cases for physician review in partnership with UM teams, ensuring care aligns with established criteria. The role requires CA RN licensure, AHA BLS, and strong UM/regulatory knowledge, with sharp analytical and organizational skills to support

Qualifications

• Must have minimum two years of acute hospital clinical experience (or a Masters in Case Management or Nursing in lieu of 1 year).
• California RN license required (must live in California).
• AHA BLS certification.
• Ability to pass annual inter-rater reliability tests for Utilization Review products.
• Familiarity with managed care and payer environments beneficial.

Responsibilities

• Review admission and continuation of stay decisions per Care Coordination Utilization Review guidelines.
• Ensure compliance with utilization review principles and regulatory criteria.
• Verify accuracy of patient status orders and address deficiencies with providers.
• Communicate review outcomes with physicians, payers, care coordinators and stakeholders.
• Collaborate with RN Care Coordinators to ensure progression of care; involve physician reviewers as needed.

Skills

Acute hospital nursing

Critical thinking

Communication skills

Team collaboration

Time management

Education

CA RN license

Master's in Case Management or Nursing

Tools

MCG/InterQual guidelines

Job description

CommonSpirit Health's St. Mary Medical Center in Long Beach, CA, seeks a Utilization Review Nurse to safeguard clinical decision-making, regulatory compliance, and efficient resource use.

You will review medical records, authorize services, and prepare cases for physician review in partnership with UM teams, ensuring care aligns with established criteria. The role requires CA RN licensure, AHA BLS, and strong UM/regulatory knowledge, with sharp analytical and organizational skills to support