Utilization Management-100

Utilization Management Registered Nurse (RN) – Outpatient Utilization Review | California Remote Contract

California Registered Nurses with utilization management experience: join a collaborative UM team reviewing medical necessity and authorizations for Medi-Cal members. This temporary contract offers remote work after required onsite training in Northern California.

As a Utilization Management Registered Nurse, you will use your clinical judgment to evaluate outpatient services, coordinate prior authorizations, and promote timely, high-quality, cost-effective care across California’s Medicaid managed care system. The training location is based in Fairfield, California, near the Bay Area and Sacramento, with access to scenic wine-country landscapes, rolling hills, and a vibrant regional community.

Utilization Management RN Job Details

• Weekly Estimated Pay: $2,461–$2,734
• Position Type: Temporary, 26-week contract
• Start Date: October 19, 2026
• Work Arrangement: Remote after training; candidates must reside in California
• Training: Approximately 2–3 weeks onsite in Northern California, including Redding-area training as assigned
• Schedule: Five 8-hour shifts per week, with Monday–Sunday coverage as scheduled
• Shift Duration: 8-hour day shifts
• Weekend Requirement: Approximately one weekend per month
• Response Standard: Medical requests must be addressed within 72 hours
• Focus Area: Outpatient utilization review, including imaging, skilled nursing, durable medical equipment, home health, and other ancillary services
• Technology: Electronic medical record and utilization management platforms; computer equipment is provided

Registered Nurse Utilization Review Requirements

• Active California Registered Nurse (RN) license
• At least 1 year of utilization management or utilization review experience required; direct UM/UR experience is essential
• Clinical experience in managed care, medical necessity review, prior authorization, or outpatient services
• Experience applying established clinical criteria and protocols; InterQual experience preferred, with Milliman experience also considered
• Knowledge of Medicaid/Medi-Cal regulations, benefit interpretation, and healthcare authorization processes preferred
• Strong clinical judgment with the ability to evaluate complex medical information and make timely decisions
• Excellent written and verbal communication skills for working with providers, members, families, and interdisciplinary teams
• Strong organization, computer proficiency, data-entry skills, and the ability to manage multiple priorities in a fast-paced environment
• Ability to work independently while collaborating effectively with clinical and operational teams
• Ability to successfully complete required onsite training and participate in a camera-ready video interview

Utilization Management Nurse Responsibilities

• Review outpatient service requests for medical necessity, appropriateness, quality, and alignment with member benefits and established clinical criteria
• Process and coordinate prior authorizations for imaging, skilled nursing, durable medical equipment, home health, and related medical services
• Conduct retrospective claims reviews and summarize findings for leadership
• Gather relevant clinical information from providers, medical records, and other healthcare sources
• Apply clinical judgment and approved guidelines to determine appropriate treatment and service recommendations
• Document and maintain accurate, patient-specific utilization management records in applicable systems
• Communicate timely authorizations, requests for additional information, and review outcomes to providers and internal teams
• Refer cases that do not meet established criteria to the appropriate clinical leadership for further review
• Monitor treatment progress and outcomes while recommending interventions that support high-quality, cost-effective care
• Collaborate with other departments to resolve authorization and service-related issues
• Participate in medical record audits, inter-rater reliability reviews, process improvement initiatives, and special projects

Apply now to join this California healthcare team as a remote Utilization Management Registered Nurse supporting quality care for Medi-Cal members.

Benefits

401K with Matching, Healthcare, Dental and Vision

Equal Opportunity

We are an equal opportunity employer and value diversity across our organization. We do not discriminate on the basis of race, religion, color, national origin, gender, sexual orientation, age, marital status, veteran status, or disability status.