Utilization Management (Remote) California License

A leading Managed Care Organization is seeking an experienced and detail-oriented Care Review Clinician II (RN or LVN) to join their Utilization Management team. This remote position plays a key role in reviewing clinical service requests, supporting continuity of care, and ensuring appropriate, cost-effective healthcare decisions are made in compliance with regulatory and clinical guidelines.

Perform clinical reviews of service requests including concurrent and prior authorization determinations Serve as clinical support to the Continuity of Care (COC) and Community Support teams Determine whether requests meet COC or community support criteria and escalate for MD review when needed Conduct provider outreach as appropriate to support authorizations and care coordination Utilize InterQual and other clinical guidelines to assess medical necessity and appropriate length of stay Ensure documentation meets compliance, quality, and turnaround standards Create and manage authorizations in accordance with established UM processes Participate in team meetings and collaborate with other departments to support member care