Utilization Management Clinical Reviewer (California) - Remote

Utilization Management Clinical Reviewer (California) - Remote Must currently reside and be a licensed RN in California Hours: Monday-Friday. Must be able to work an 8-hour shift between 8:00 a.m.-5:00 p.m. PST. In this role, you will manage an active caseload, assess clinical needs and levels of care, identify barriers to discharge, and coordinate safe transitions across the care continuum. You will collaborate with members, families, providers, facilities, and internal partners while balancing quality, affordability, benefit coverage, and member advocacy . The role requires strong communication, organization, critical thinking, sound clinical judgment, and the ability to work independently in a remote environment. It also requires strong computer skills, including the ability to navigate multiple systems, document accurately, manage several tasks at once, and use technology effectively throughout the workday. This is a fast-paced role that may involve a high volume of inbound and outbound phone interactions while managing multiple priorities and documentation requirements. Help improve health outcomes by guiding members through complex inpatient care. In this role, you will manage an active caseload, assess clinical needs and levels of care, identify barriers to discharge, and coordinate safe transitions across the care continuum. You will collaborate with members, families, providers, facilities, and internal partners while balancing quality, affordability, benefit coverage, and member advocacy.

Manage and coordinate an assigned caseload of complex, high-acuity, or account-sensitive inpatient cases. Complete prospective, concurrent, and retrospective clinical reviews for acute inpatient care, rehabilitation, referrals, select outpatient services, and durable medical equipment, as applicable. Apply approved clinical guidelines and tools to evaluate medical necessity, level of care, covered services, treatment goals, risk factors, and discharge needs. Review the daily census, prioritize cases, request relevant clinical information, and document decisions, interventions, and outcomes accurately and on time. Create member-centered short- and long-term care plans with measurable goals, follow-up timeframes, and clear criteria for transition or closure. Coordinate with members, families, physicians, facilities, vendors, caregivers, and internal partners to support timely discharge or transfer to the appropriate level of care. Identify and help resolve gaps in care, barriers to discharge, risk for readmission, and delays in services. Educate members about available benefits, care options, costs, and community resources so they can take an active role in health care decisions. Serve as a member advocate and liaison while working within benefit, regulatory, contractual, and program requirements. Escalate complex cases, quality-of-care concerns, and service delays to the appropriate manager, medical director, or Quality partner. Identify referrals for complex or specialty case management programs and coordinate a smooth transition when needed. Build effective relationships with internal teams, providers, customers, and community resources. Support customer or auditor visits, special projects, peer consultation, and other related duties as assigned.

Active, unencumbered California RN licensure A minimum of two years of direct clinical RN experience in an inpatient or managed care setting Preferred Qualifications Bachelor’s degree in nursing or a related field. Ability to assess complex clinical information, identify barriers, recommend solutions, and make sound decisions. Strong written and verbal communication, organization, time management, research, analytical, negotiation, and problem-solving skills. Ability to work independently, manage competing priorities, and collaborate in a fast-paced, matrixed environment. Proficiency using computers and clinical or case management systems.