Utilization Management Nurse Reviewer (RN/LVN)

Universal Healthcare MSO LLC; Bakersfield (CA); On-site; USD 43,000 - 75,000; Full time

Benefits offered by this job

Medical

Dental

Vision

Simple IRA Plan with Employer Contrib.

Employer Paid Life Insurance

Employee Assistance Program

Job summary

Universal Healthcare MSO LLC seeks an experienced Utilization Management Nurse Reviewer to conduct timely pre-certification and concurrent reviews, ensuring appropriate medical necessity and efficient discharge planning. You will collaborate with physicians, case managers, and payers to optimize member care.

Responsibilities include applying CMS, InterQual, and health plan guidelines, documenting activities, and guiding junior staff while maintaining compliance with federal and state

Qualifications

• Active Unrestricted California RN or LVN license.
• Experience in managed care, utilization management, disease management, or related fields preferred.
• Strong communication and analytical skills are required.

Responsibilities

• Perform utilization reviews (pre-certification, concurrent, retrospective) per regulatory guidelines.
• Assess medical necessity of requested services using CMS, InterQual, and payer guidelines.
• Ensure proper discharge planning and transition of care.
• Communicate review outcomes via system letters and documentation.
• Collaborate with multidisciplinary teams and providers to coordinate care.
• Identify high-risk members and coordinate appropriate interventions.

Skills

RN license

LVN license

Utilization management

CMS guidelines

InterQual knowledge

Communication skills

Problem solving

PC software

Tools

PC software

Job description

Universal Healthcare MSO LLC seeks an experienced Utilization Management Nurse Reviewer to conduct timely pre-certification and concurrent reviews, ensuring appropriate medical necessity and efficient discharge planning. You will collaborate with physicians, case managers, and payers to optimize member care.

Responsibilities include applying CMS, InterQual, and health plan guidelines, documenting activities, and guiding junior staff while maintaining compliance with federal and state