Utilization Management Nurse Auditor

University of California - Los Angeles Health; Los Angeles (CA); On-site; USD 98,000 - 215,000; Full time

Job summary

University of California - Los Angeles Health is seeking an Utilization Management Nurse Auditor to provide clinical review, audits, and quality improvement support across the health system. You will conduct concurrent and retrospective reviews, support denials appeals, and analyze trends to drive utilization performance.

The role requires a California RN license, 5+ years in healthcare, and strong knowledge of payment and audit processes.

Qualifications

• Bachelor's degree in Nursing or allied healthcare field; applicable education/experience accepted.
• Five+ years of healthcare experience in clinical, quality improvement, utilization management, or related setting.
• Three+ years in utilization management, case management, or clinical auditing.
• Active, unrestricted RN license in California.
• Proficiency with UM criteria (InterQual/MCG) and payer requirements.
• Strong data analysis, reporting, and documentation skills.
• Excellent written and verbal communication; ability to work with physicians and leadership.
• Experience with electronic health records and reporting tools (Epic familiarity).
• Project management and organizational skills to handle multiple priorities.

Responsibilities

• Review concurrent and retrospective clinical denials to assess admission status and level of care.
• Prepare documentation for first- and second-level appeals and support payer/audit responses.
• Analyze denial trends to identify root causes and opportunities for improvement.
• Evaluate cases using utilization criteria and escalate complex cases as needed.
• Collaborate with physicians, care coordination, and Revenue Cycle to strengthen medical necessity support.
• Prepare dashboards, reports, and summaries for leadership and UM committee review.
• Support performance improvement initiatives focused on length of stay and denial rates.
• Serve as a clinical resource across the health system for utilization management and quality.

Skills

Utilization management

Clinical auditing

Data analysis

InterQual/MCG

Payer requirements

Project management

Communication

Collaboration

Epic

Quality improvement

Education

Bachelor's degree in Nursing

California RN license

Tools

Epic

Job description

Description

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 escalates 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

Qualifications

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