• Job Type: Full-time

• Schedule: Monday - Friday 8:00 AM – 5:00 PM PST
• Location: Remote (California license required - CA is NOT a compact state))

Job Summary We’re seeking an experienced Utilization Management Nurse (RN or LVN) to support inpatient review and care coordination for patients requiring ongoing medical oversight. This role is designed for nurses who want to make an impact by ensuring patients receive safe, appropriate, and cost-effective care. You’ll partner with physicians, hospital staff, and case managers to coordinate treatment plans and transitions of care. This position is remote, though an active California nursing license is required.

• Responsibilities
• Perform inpatient concurrent reviews and assess admissions/continued stays using MCG (Milliman Care Guidelines).
• Provide oversight for patients with complex or chronic conditions, identifying those who may require post-discharge case management.
• Communicate with physicians, case managers, and discharge planners to coordinate patient care plans.
• Participate in interdisciplinary team meetings and patient rounds.
• Accurately document clinical activities and case updates in the care management system.
• Track case progress and provide updates to UM leadership.
• Monitor for overutilization or underutilization patterns and escalate concerns when needed.

Qualifications

• Required:
• Current, unrestricted California RN or LVN license.
• At least 2 years of inpatient review, case management, or utilization management experience.
• Familiarity with evidence-based criteria such as Milliman Care Guidelines (MCG) and CMS Guidelines.
• Preferred (not required):
• 3+ years of nursing experience in a managed care setting.
• IPA or Health Plan experience
• Background in Medicare Managed Care.
• Experience with utilizing clinical criteria such as Milliman, InterQual, CMS National and Local Coverage Determinations (LCD).
• Associates or Bachelor’s degree in Nursing.
• Strong critical thinking and problem-solving skills.
• Excellent communication and interpersonal abilities.
• Comfortable working in a fast-paced environment with multiple priorities.
• Proficiency in Microsoft Word, Excel, and Outlook.
• What We Offer
• Remote position – work from home with a California license.
• Competitive compensation (range dependent on location and experience).
• Comprehensive benefits package, including:
• Medical, dental, and vision insurance.
• 401(k) retirement plan with employer contributions.
• Paid time off, personal days, and holidays.
• Life insurance and disability coverage.
• Ongoing training and career development opportunities.

Job Type: Full-time Pay: $100,000.00 - $105,000.00 per year

• Benefits:
• 401(k)
• 401(k) matching
• Dental insurance
• Disability insurance
• Employee assistance program
• Employee discount
• Flexible schedule
• Flexible spending account
• Health insurance
• Health savings account
• Life insurance
• Paid time off
• Parental leave
• Professional development assistance
• Referral program
• Retirement plan
• Travel reimbursement
• Vision insurance
• Experience:
• CMS Guidelines: 1 year (Required)
• Utilization Management Inpatient Review: 1 year (Required)
• Medicare: 1 year (Required)
• Inpatient/Concurrent Utilization Review: 1 year (Required)
• Language:
• Fluent Spanish (Preferred)
• License/Certification:
• Unexpired CALIFORNIA Nursing License (CA is NOT compact) (Required)
• Location:
• United States (Required)

Work Location: Remote