Utilization Management Nurse

Valley Children's Healthcare; Madera (CA); Hybrid; USD 90,000 - 130,000; Full time

Job summary

Valley Children's Healthcare in California seeks an experienced Utilization Management Nurse to support the Case Management Department by applying clinical criteria to admissions and payer requirements.

This hybrid, full-time role involves denial management, collaboration with physicians and payors, and providing staff with guidance on utilization management standards, while ensuring regulatory compliance and efficient resource use.

Qualifications

• Associate Degree in Nursing (required).
• California RN license (required).
• Minimum 3 years RN experience in an acute care hospital.
• Pediatric nursing and Case Management experience preferred.
• Knowledge of utilization management regulations and payer practices.

Responsibilities

• Perform daily screening of admissions against clinical criteria.
• Active involvement in denial management.
• Serve as clinical resource on utilization criteria for staff.
• Communicate with payors to address utilization concerns.
• Support compliance with regulatory and departmental requirements.

Skills

Clinical nursing expertise

Utilization management knowledge

Communication skills

Interprofessional collaboration

Prioritization & multitasking

Proficiency with office software

Education

Associate Degree in Nursing

Bachelor’s Degree in Nursing or related field

Job description

The Utilization Management Nurse supports the Case Management Department by performing a variety of utilization management functions to promote appropriate patient care, support regulatory and payer requirements, and ensure effective utilization of healthcare resources.

The Utilization Management Nurse is responsible for the daily screening of patient admissions against specified clinical criteria, active involvement in denial management, and serving as a clinical resource to staff regarding utilization management criteria and requirements. This position also communicates with payors to address clinical and utilization concerns and performs other duties as assigned.

Working collaboratively with the Utilization Management Program Coordinator, the Utilization Management Nurse helps ensure compliance with regulatory, organizational, and departmental requirements. The nurse will receive direction from the Program Coordinator regarding daily responsibilities, as well as longer-term projects and initiatives.

Schedule

• Full-time
• Shift: 11:00 a.m. – 7:30 p.m. with rotating weekend coverage
• Hybrid Position – Primarily remote/work-from-home, with an expectation to be on-site at least once per month, or more frequently as business needs or projects require. Candidates must reside locally and be able to commute to the worksite as needed.

Education

• Associate Degree in Nursing (required)
• Bachelor’s Degree in Nursing or related field (preferred)

Licenses & Certifications

• Current Registered Nurse (RN) license in the State of California (required)

Required Experience

• Minimum of three (3) years of full-time equivalent RN experience in an acute care hospital

Preferred Experience

• Pediatric nursing experience
• Experience in Case Management and/or Utilization Review

Skills & Qualifications

• Knowledge of utilization management regulations and requirements
• Knowledge of private and public payer reimbursement practices and procedures
• Excellent organizational, communication, and interpersonal skills
• Ability to collaborate effectively with physicians, nurses, case managers, payors, and other healthcare professionals
• Ability to work independently and manage multiple priorities
• Strong clinical judgment and attention to detail
• Proficiency with computer applications, including word processing, spreadsheets, and database software
• Ability to apply clinical criteria and payer requirements to support appropriate utilization and patient care

Why Join Us?

This is an opportunity for an experienced acute care RN to bring their clinical expertise into a utilization management role, working collaboratively with the Case Management team and healthcare partners to support quality patient care and effective resource utilization.