RN Utilization Management Nurse (Active CA RN license required)

Review clinical information for medical necessity determinations of provider service requests for the inpatient and outpatient services. Perform initial and ongoing reviews for inpatient admissions, level of care, observation, pre-service, concurrent review and discharge planning in accordance with Customer’s inpatient policy and procedures, medical policy guidelines, MCG decision support criteria and MediCal/CMS regulatory requirements. Process requests for prior authorization of outpatient services in accordance with Customer’s inpatient policy and procedures, medical policy guidelines, MCG decision support criteria and MediCal/CMS regulatory requirements. Conduct all medical necessity clinical reviews in Customer’s care management platform for full transparency and tracking of Nurse activities and performance measures. Participate in department meetings, training, and audit activities equal to Customer employees.