Utilization Review Nurse

Pacific Staffing; Sacramento (CA); Hybrid; USD 74,390 - 90,921; Full time

Job summary

A prominent healthcare staffing agency is seeking a Utilization Review Nurse in Sacramento, CA, responsible for managing the daily operations of the UM Pre-Authorization team. The ideal candidate will ensure accurate processing of referral requests, maintain regulatory compliance, and have strong leadership skills. The position requires 7+ years of UM experience and offers a pay range of $54-$66/hour as a hybrid role. Join a collaborative environment dedicated to quality healthcare delivery.

Qualifications

• 5+ years of clinical nursing experience required.
• 3+ years of utilization management experience in a health plan or UM operations required.
• Graduate of an accredited school of nursing.

Responsibilities

• Oversee operations of the Pre-Authorization team and ensure timely operations.
• Ensure accurate preparation of referral files for review.
• Foster strong working relationships with medical staff.

Skills

Clinical nursing experience

Leadership skills

Interpersonal communication

Regulatory compliance knowledge

Data analysis

Education

Bachelor’s degree in Nursing or equivalent

Registered Nurse (CA) license

Tools

Microsoft Office (Word, Excel)

Job description

We are recruiting for a Utilization Review Nurse to join a large healthcare organization within the Sacramento region. The Utilization Review Nurse is responsible for overseeing the daily operations of the UM Pre-Authorization team, ensuring referral requests are processed consistently, accurately, and within regulatory timeframes. This position plays a key role in workflow oversight, staff support, regulatory compliance, and collaboration with internal and external partners. The ideal candidate will have 7+ years of UM experience with charge, lead, supervisory, or management responsibilities and experience working with health plan auditors.

• Pay range: $54-$66/hour DOE
• Hybrid
• License Required: Registered Nurse – CA
• 6-month contract role

PRIMARY RESPONSIBILITIES:

• Oversee day‑to‑day operations of the Pre‑Authorization team, ensuring timely response and appropriate evaluation of referral reviews.
• Ensure correct selection and application of clinical criteria and accurate preparation of cases for UM Physician Reviewers when indicated.
• Ensure timely verbal and written documentation and completion of referral files.
• Maintain adequate staffing levels, assign work appropriately, and adjust workflow to meet departmental goals.
• Organize, structure, and chair at least one pre‑authorization meeting per month, involving additional staff as appropriate.
• Motivate and coach staff, including new‑hire training, problem‑solving support, and participation in special projects.
• Assist the Manager with performance activities, including monitoring, coaching, education, and providing feedback to team members.
• Develop a Pre‑Authorization team that is consistent, knowledgeable, accurate, and committed to meeting timelines.
• Ensure UM Physicians receive all relevant information needed for accurate referral review.
• Foster strong working relationships between the Pre‑Authorization team, the Medical Director, and Physician Reviewers.
• Promote appropriate application of clinical criteria, policies, and guidelines to prior‑authorization referrals.
• Participate in audit preparation and serve as a resource during health plan audits.
• Monitor, compile, analyze, and report UM data, trends, and performance metrics.

SKILLS & QUALIFICATIONS:

• Graduate of an accredited school of nursing.
• Registered Nurse (CA) license required.
• Bachelor’s degree in Nursing or equivalent experience required.
• 5+ years of clinical nursing experience required.
• 3+ years of utilization management experience in a health plan, UM operations, acute care, or subacute utilization review required.
• Demonstrated leadership and management skills.
• Knowledge of applicable federal/state regulations and accreditation standards.
• Working knowledge of UM review processes and regulatory requirements.
• Ability to monitor, compile, analyze, and report data/statistics.
• Excellent interpersonal, written, and verbal communication skills.
• Demonstrated ability to lead, mentor, and develop staff.
• Ability to work effectively with all levels of the organization and external partners.
• Proficiency with Microsoft Office (Word, Excel) and other clinical/administrative systems.