Utilization Management Nurse, RN (Remote)

Inland Empire Health Plan; California; Remote; USD 85,000 - 110,000; Full time

Benefits offered by this job

Competitive salary

Telecommute schedule

State of the art fitness center on‑sit

Medical Insurance with Dental and Vis

Life, short‑term, and long‑term)

Career advancement opportunities and p

Wellness programs that promote a work‑

Flexible Spending Account – HealthCare

CalPERS retirement

457(b) option with a contribution matc

Paid life insurance for employees

Pet care insurance

Job summary

IEHP is seeking an experienced Utilization Management Nurse in California to lead prospective, concurrent and retrospective reviews of referrals, ensuring regulatory compliance and clear member correspondence.

Under the guidance of the UM Manager, you will apply nationally recognized UM criteria, assess medical necessity, and collaborate with physicians and care teams to meet members' needs while supporting IEHP's commitment to quality and patient-centered care.

Qualifications

• Two years direct clinical patient care in an acute care setting with an active RN license.
• Experience in an HMO or Managed Care setting preferred.
• California RN license active and unencumbered is required.
• Bachelor’s degree in Nursing preferred.

Responsibilities

• Prospectively, concurrently, and retrospectively review referrals to ensure regulatory requirements are met.
• Ensure member correspondence uses appropriate UM criteria and clear language.
• Apply nationally recognized UM criteria to determine medical necessity and benefits.
• Communicate findings and recommendations to physicians and care teams to support patient care.

Skills

UM criteria knowledge

Nursing practice

Medical terminology

Regulatory compliance

Communication skills

Caseload management

Analytical thinking

Education

RN license

Bachelor’s degree in Nursing

Job description

What you can expect!

Find joy in serving others with IEHP! We welcome you to join us in “healing and inspiring the human spirit” and to pivot from a “job” opportunity to an authentic experience!

Under the general direction of the Utilization Management Manager, the Utilization Management Nurse is responsible for prospective and concurrent/retrospective review of referrals ensuring regulatory requirements are being met as they relate to language readability and appropriate citation of criteria in Member correspondence. This position is responsible to ensure meeting Member’s needs using nationally recognized UM criteria.

Commitment to Quality: The IEHP Team is committed to incorporate IEHP’s Quality Program goals including, but not limited to, HEDIS, CAHPS, and NCQA Accreditation.

Perks

IEHP is not only committed to healing and inspiring the human spirit of our Members, but we also aim to match our team members with the same energy by providing prime benefits and more

• Competitive salary
• Telecommute schedule
• State of the art fitness center on-site
• Medical Insurance with Dental and Vision
• Life, short‑term, and long‑term disability options
• Career advancement opportunities and professional development
• Wellness programs that promote a healthy work‑life balance
• Flexible Spending Account – Health Care/Childcare
• CalPERS retirement
• 457(b) option with a contribution match
• Paid life insurance for employees
• Pet care insurance

Education & Requirements

• A minimum of two (2) years of direct, hands‑on clinical patient care experience in an acute care facility utilizing an active RN license is required.
• Experience in an HMO or experience in a Managed Care setting preferred
• High school diploma or GED required
  • Bachelor's degree in nursing from an accredited institution preferred
• Possession of an active, unrestricted, and unencumbered Registered Nurse (RN) license issued by the California BRN required

Key Qualifications

• Strong knowledge and understanding of:
  
  • Nationally recognized UM criteria.
    
  • Title 22, Title 10, DMHC, DHCS, CMS, and state regulatory requirements specifically as they relate to UM/Health Plan correspondence.
    
  • Clinical nursing practice, standards of care, and medical terminology
    
  • Medical necessity standards and benefit interpretation.
    
• Strong proficiency in the following areas:
  
  • Clinical assessment and documentation skills. Skills in documenting UM referral reviews accurately.
    
  • Communication skills (both written and verbal).
    
  • Critical thinking skills.
    
  • Abstracting and interpreting medical information from clinical records.
    
• Demonstrated ability to:
  
  • Express or exchange ideas to impart information to the public and to convey detailed instructions to staff accurately and quickly.
    
  • Manage caseload efficiently.
    
  • Exhibit a high attention to detail.
    
  • Work at a high level of speed while maintaining accuracy.
    
  • Work well with both physicians and nursing staff.

Start your journey towards a thriving future with IEHP and apply TODAY!