Utilization Management Nurse Auditor

UCLA Health; Los Angeles (CA); Hybrid; USD 98,000 - 215,000; Full time

Job summary

UCLA Health is seeking an Utilization Management Nurse Auditor in Los Angeles to support clinical review, audit, and quality improvement across the health system.

The role conducts concurrent and retrospective reviews, supports appeals, analyzes utilization trends, and collaborates with Revenue Cycle, Care Coordination, and Physician Advisory teams to strengthen medical necessity determinations and payer compliance. Strong data skills and Epic proficiency are essential.

Qualifications

• Bachelor’s degree in Nursing or a related healthcare field.
• Five or more years of professional healthcare experience in a clinical, quality improvement, utilization management, or related setting.
• Three or more years of experience in utilization management, case management, and/or clinical auditing.
• Active, unrestricted Registered Nurse license in California.
• Thorough knowledge of utilization management criteria (InterQual/MCG) and payer requirements.

Responsibilities

• Review concurrent and retrospective denials to assess admission status, level of care, length of stay, and medical necessity.
• Prepare clinical summaries and documentation for first- and second-level appeals and collaborate on audit responses.
• Analyze denial and audit findings to identify trends and opportunities for improvement in utilization management.
• Evaluate cases using established criteria (InterQual/MCG) and elevate complex cases as needed.
• Collaborate with Physician Advisors and Care Coordination teams to improve documentation of medical necessity and status designation.
• Prepare reports, dashboards, and presentations for leadership and Utilization Management Committee.
• Support performance improvement initiatives targeting length of stay, denial rates, and data integrity.

Skills

Utilization management

Clinical auditing

Data analysis

Communication

Report writing

Cross-functional collaboration

Education

Bachelor’s degree in Nursing or related healthcare field

Tools

Epic

Job description

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Onsite or Remote

Flexible Hybrid

Work Schedule

Monday - Friday, 8AM - 5PM

Posted Date

09/10/2026

Salary Range: $98200 - 214600 Annually

Employment Type

Duration

Indefinite

Job #

32733

Primary Duties and Responsibilities

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Patient Business Services

Provide clinical review, audit, analytical, and quality improvement support for utilization management, medical necessity determinations, and denial prevention and response efforts across the health system. As the Utilization Management Nurse Auditor, you will conduct concurrent and retrospective case reviews, support denial appeals, analyze utilization and denial trends, and collaborate with Care Coordination, Clinical Documentation Integrity, Revenue Cycle, and Physician Advisor teams. This role helps strengthen level-of-care determinations, clinical documentation, payer compliance, and operational and financial performance.

In this role, you will:

• Review concurrent and retrospective clinical denials to assess admission status, level of care, length of stay, medical necessity, and other factors contributing to denials.
• Prepare clinical summaries and supporting documentation for first- and second-level appeals, support payer, RAC, and Medi-Cal audit responses, and collaborate with Revenue Cycle and Physician Advisor teams to strengthen appeal strategies.
• Analyze denial and audit findings to identify trends, root causes, documentation gaps, avoidable delays, and opportunities to improve utilization management performance.
• Evaluate cases using established utilization review criteria, including InterQual, MCG, organizational guidelines, and payer requirements, and elevate complex or questionable cases as appropriate.
• Partner with Physician Advisors, Care Coordination teams, and clinical staff to improve documentation supporting medical necessity, status designation, and accurate level-of-care determinations.
• Prepare reports, dashboards, presentations, case summaries, trend analyses, and recommendations for leadership and Utilization Management Committee review.
• Support performance improvement initiatives focused on length of stay, avoidable days, denial rates, status accuracy, utilization outcomes, and data integrity.
• Serve as a clinical resource while collaborating with clinical and operational leaders across the health system to support utilization management, clinical quality, patient safety, care progression, discharge planning, and continuous improvement efforts.

Salary Range:
$98,200 to $214,600 annually

Job Qualifications

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Required

• Bachelor’s degree in Nursing or a related healthcare field, or an equivalent combination of healthcare education and experience.
• Five or more years of professional healthcare experience in a clinical, quality improvement, utilization management, or related setting.
• Three or more years of experience in utilization management, case management, and/or clinical auditing.
• Active, unrestricted Registered Nurse license in California.
• Thorough knowledge of utilization management criteria, including InterQual and MCG guidelines.
• Thorough knowledge of payer requirements, medical necessity determinations, and denial management processes.
• Advanced knowledge of quality improvement standards, clinical chart review, abstraction methodologies, and regulatory requirements.
• Ability to use data collection, aggregation, validation, analysis, and reporting techniques to support utilization management and quality improvement activities.
• Strong analytical and critical thinking skills with the ability to interpret complex clinical, operational, and financial information.
• Strong written and verbal communication skills for preparing reports, summaries, recommendations, and appeal documentation.
• Ability to collaborate effectively with physicians, clinical staff, operational leaders, and external regulatory representatives.
• Proficiency with electronic health records and healthcare data management applications, including familiarity with systems such as Epic.
• Project management and organizational skills with the ability to manage multiple priorities and deadlines.

Preferred

• Master’s degree in Healthcare Administration, Public Health, Business Administration, or a related field.
• Certification in Case Management (CCM), Certified Professional Utilization Review (CPUR), Certified Professional Coder (CPC), or a related specialty.
• AAPC certification, such as Certified Professional Coder, Certified Professional Biller, or Revenue Cycle Management Specialist

As a condition of employment, the final candidate who accepts an offer of employment will be required to disclose if they have been subject to any final administrative or judicial decisions within the last seven years determining that they committed any misconduct; or have filed an appeal of a finding of substantiated misconduct with a previous employer. Current/former UC employees are subject to a personnel file review.