Remote Utilization Management Nurse (RN or LVN – CA Lic. Req.) | Prior Authorization Preservice

🌍 Remote, USA 🎯 Full-time 🕐 Posted Recently

Job Description

Remote Utilization Management Preservice Nurse (RN or LVN – California License Required)
Contract-to-Permanent Hire | Fully Remote (U.S.)

May reside anywhere in the US as long as you have an active California RN or LNV license.

A rapidly growing healthcare services organization is seeking a Utilization Management Nurse (RN or LVN) to support pre-service and prior authorization reviews. This role plays a key part in ensuring patients receive appropriate, timely, and cost-effective care while working collaboratively with physicians, care teams, and healthcare providers.

This is a 100% remote opportunity open to candidates anywhere in the United States, however an active California RN or LVN license is required.

This position begins as a contract role with strong potential for permanent hire based on performance.

Tuesday – Saturday | 8:00 AM – 5:00 PM PST
Monday - Friday | 8:00 AM – 5:00 PM PST

Review prior authorization and pre-service requests for inpatient and outpatient care.
Evaluate medical necessity using clinical guidelines such as MCG, InterQual, or comparable evidence-based criteria.
Collaborate with physicians, providers, case managers, and medical directors to support care determinations.
Verify patient eligibility, benefits, and accuracy of medical coding (ICD-10, CPT).
Ensure requests are processed within required turnaround times while maintaining accurate documentation.
Provide clinical input for appeals and grievance reviews when necessary.
Communicate professionally with providers, patients, and internal teams regarding care decisions.
Assist with single-case agreements or out-of-network service reviews when applicable.
Participate in team meetings, case discussions, and quality improvement initiatives.

Active, unrestricted California RN or LVN license
Minimum 1 year of Medicare experience
Experience or familiarity with utilization management, prior authorization, or clinical review
Understanding of medical terminology, coding (ICD-10/CPT), and CMS guidelines
Strong critical thinking and clinical decision-making skills
Excellent written and verbal communication
Ability to manage multiple requests and meet deadlines in a fast-paced environment
Proficiency with Microsoft Office (Word, Excel, Outlook)

2+ years of experience in utilization management, managed care, or hospital settings
Experience using MCG (Milliman), InterQual, or similar clinical guidelines
Familiarity with Medicare Managed Care Plans

Contract-to-Permanent Hire Opportunity
100% Remote Work Environment
Medical, dental, and vision insurance
401(k) with employer contributions
Professional development and training opportunities

Apply today if you're a licensed California RN or LVN looking for a remote role in utilization management with long-term career potential.

Equal Opportunity Employer

We are an Equal Opportunity Employer and are committed to fostering a diverse and inclusive workplace. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, gender identity, sexual orientation, pregnancy, national origin, age, disability, genetic information, veteran status, or any other characteristic protected by applicable federal, state, or local laws.

Job Type: Full-time

Pay: $100,000.00 - $105,000.00 per year