Location: Fully remote. Candidates must be available to work Pacific Time hours, Monday through Friday, from 8:00 a.m. to 5:00 p.m.
Description:Join a fast-growing, dynamic team that is redefining how Utilization Management supports value-based care.
This clinically driven Utilization Management model focuses on ensuring members receive the right care, from the right provider, at the right time. As part of a high-impact transformation initiative, you will strengthen clinical decision-making, improve referral appropriateness, and support better outcomes for members and provider partners.
We are seeking an experienced Managed Care Registered Nurse with exceptional clinical judgment, extensive Prior Authorization experience, and a passion for improving healthcare delivery. This is an opportunity to help shape the future of Utilization Management while working alongside physician leaders and cross-functional teams committed to transforming care.
What You Will Do:- Perform prospective and retrospective utilization reviews for inpatient, outpatient, and specialty services using evidence-based clinical criteria and nationally recognized guidelines, including MCG.
- Review prior authorization requests to determine medical necessity and clinical appropriateness, ensuring services are delivered at the appropriate level of care and by the appropriate provider.
- Evaluate referrals within high-impact specialty areas, including: Advanced Imaging, Hematology/Oncology, Orthopedic Surgery, Home Health, and Specialty Services
- Apply strong clinical judgment to identify opportunities for members to receive appropriate care within the primary care setting when clinically appropriate.
- Collaborate closely with Medical Directors on complex cases requiring physician review and medical necessity determinations.
- Partner with physicians, care management teams, network management, quality improvement, and practice operations to support coordinated, patient-centered care.
- Interface with health plans, providers, vendors, and regulatory agencies throughout the utilization management process.
- Ensure compliance with CMS, NCQA, DMHC, health plan requirements, organizational policies, and evidence-based clinical guidelines.
- Maintain accurate documentation within Epic Tapestry and other clinical systems, including ICD-10, CPT, and HCPCS coding, as appropriate.
- Participate in annual inter-rater reliability reviews and demonstrate consistent application of clinical guidelines.
- Contribute to process improvement initiatives designed to strengthen Utilization Management, improve referral quality, and support value-based care outcomes.
You Will Be Successful If:- You demonstrate exceptional clinical judgment and confidence when reviewing complex prior authorization requests.
- You understand that Utilization Management extends beyond approving or denying services and focuses on delivering the most appropriate care for each member.
- You possess extensive knowledge of managed care operations, Medicare Advantage, and evidence-based utilization review.
- You effectively collaborate with physicians and interdisciplinary teams while maintaining strong provider relationships.
- You thrive in a fast-paced, evolving environment focused on continuous improvement and operational excellence.
- You are comfortable working independently, managing competing priorities, and maintaining high-quality clinical decision-making.
- You embrace change and enjoy helping build new care-delivery models that improve outcomes for members and providers.
What You Will Bring:- An active, unrestricted Registered Nurse license.
- A minimum of five years of Utilization Management experience within a Medicare Advantage health plan, Independent Practice Association, Management Services Organization, delegated medical group, or managed care organization.
- Extensive Prior Authorization experience across inpatient and outpatient services.
- Demonstrated expertise applying MCG Care Guidelines in complex utilization management reviews.
- Strong knowledge of Medicare Advantage regulations, CMS requirements, and medical necessity review.
- Experience reviewing referrals involving one or more of the following: Advanced Imaging, Hematology/Oncology, Orthopedic Surgery, Home Health, and Specialty Referrals
- Experience collaborating with Medical Directors and supporting physician review processes.
- Strong knowledge of ICD-10, CPT, and HCPCS coding.
- Excellent written and verbal communication skills.
- The ability to work independently in a fully remote environment while maintaining productivity and quality standards.
Preferred Qualifications
- Experience with Epic Tapestry.
- Previous experience within a delegated managed care model or Management Services Organization.
- Familiarity with InterQual criteria.
- Experience participating in Utilization Management transformation or process improvement initiatives.
- Lean, Six Sigma, or workflow optimization experience.
