Clinical Resources NurseWestern Health Advantage📍
Sacramento, CA (Hybrid)💲
Salary: $95,000-$115,000 annuallySummary DescriptionWestern Health Advantage is seeking a knowledgeable and collaborative
Clinical Resources Nurse (CRN) to support Utilization Management activities at the corporate health plan level. Reporting to the Utilization Operations Director, the CRN partners closely with WHA's Chief Medical Officer, Assistant Medical Director, Clinical Pharmacists, and operational teams to promote timely access to medically necessary, high-quality care.
This position supports complex utilization reviews, out-of-area care, transitions and continuity of care, benefit interpretation, delegation oversight, and regulatory compliance. The CRN also works directly with contracted IPAs and medical groups to coordinate care, resolve clinical and benefit-related questions, and support the needs of WHA members.
What You'll Do- Research, evaluate, and prepare complex cases involving new medical technologies, experimental treatments, organ transplants, cancer clinical trials, second opinions, and other specialized services.
- Review pre-service requests for which WHA holds financial risk, confirming eligibility, medical necessity, and access to contracted providers.
- Coordinate letters of agreement when medically necessary services are not available through contracted providers.
- Perform telephonic concurrent reviews for members admitted through emergency departments to out-of-area hospitals.
- Collaborate with hospital discharge planners and medical group clinical teams to support appropriate transfers, safe discharges, and in-network follow-up care.
- Screen and coordinate Continuity of Care requests for eligible members experiencing provider or medical group transitions.
- Prepare cases for review by the Chief Medical Officer or Assistant Medical Director and ensure timely follow-up, including authorization, approval, and denial notifications.
- Assist Member Services representatives and medical group Utilization Management teams with benefit interpretation, eligibility requirements, and regulatory compliance questions.
- Provide direction and clinical guidance to Intake Coordinators and collaborate with the Clinical Resources Intake Supervisor.
- Maintain and update clinical reference materials, including WHA's Prior Authorization and Durable Medical Equipment Benefit Matrix.
- Support DMHC regulatory reviews, NCQA accreditation audits, delegation oversight audits, and clinical chart abstractions.
- Serve as a clinical liaison and resource for assigned medical groups and delegated entities.
- Coordinate with Quality Management staff to screen cases identified as potential quality issues.
- Initiate and follow up on referrals for Case Management, Disease Management, and Behavioral Health services.
- Provide care coordination, education, and support for members receiving transgender surgical services.
- Support WHA's sales, marketing, and wellness activities by developing or reviewing clinical materials, presentations, and educational programs.
- Assist with the development of educational resources related to health plan benefits and Utilization and Case Management processes.
- Complete additional duties and special projects as assigned.
What You'll Bring- Bachelor's degree in Nursing.
- Active California Registered Nurse (RN) or Licensed Vocational Nurse (LVN) license, maintained throughout employment.
- At least three years of clinical experience.
- At least one year of experience in utilization management, case management, discharge planning, or a managed care environment.
- Strong knowledge of care coordination, utilization review, benefit interpretation, and managed care operations.
- Ability to evaluate complex clinical information and collaborate effectively with physicians, pharmacists, nurses, operational teams, and delegated medical groups.
- Intermediate computer skills, including email, databases, word processing, spreadsheets, and presentation or graphics applications.
- Proficiency in creating formulas and graphs in Microsoft Excel and incorporating them into Word documents.
- Ability to speak, read, write, and understand the primary language used in the workplace.
- Utilization Management, Quality Management, or Certified Case Manager certification is preferred but not required.
