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Remote Utilization Management Nurse (Pre-Service Review – RN or LVN) Must have CALIFORNIA license.
Job Type: Full-time Schedule: Tuesday - Saturday OR Sunday - Thursday 8:00 AM – 5:00 PM (PST) Location: Anywhere in the US, Remote (California RN or LVN license required) Job Summary MUST HAVE CALIFORNIA LICENSE. We are seeking a detail-oriented Utilization Management Nurse (Pre-Service / Prior Authorization Review) to join our growing clinical team. This role focuses on reviewing pre-certification requests for inpatient and outpatient services, ensuring patients receive the right care at the right time. You’ll collaborate with providers, case managers, and medical directors to support high-quality, arenaflex-effective care delivery. This position is fully remote, but requires an active California RN or LVN license. Responsibilities • Review pre-service authorization (prior auth) requests for medical necessity using evidence-based guidelines (MCG, InterQual, or similar). • Collaborate with providers, physicians, and medical directors on care determinations. • Verify eligibility, benefits, and accuracy of submitted medical codes (ICD-10, CPT). • Process requests within required turnaround times while documenting all activities accurately. • Support appeals and grievances by providing clinical input when needed. • Maintain professional communication with providers, patients, and internal staff. • Assist with single-service agreements when services are out of network. • Participate in team calls, case discussions, and process improvement initiatives. Qualifications Required: • Active, unrestricted California LVN or RN license. • 1+ year of experience with Medicare or Medicaid. • Familiarity with utilization management, medical terminology, and coding. Preferred (not required): • 2+ years of experience in a managed care or hospital setting. • Prior use of Milliman (MCG), InterQual, or CMS guidelines. • Knowledge of Medicare Managed Care Plans. • Associates or Bachelor’s degree in Nursing. • Certification such as CPHQ, ABQAURP, or Six Sigma. • Strong critical thinking and problem-solving skills. • Excellent written and verbal communication. • Ability to prioritize multiple tasks and meet deadlines in a fast-paced environment. • Proficiency in arenaflex Word, Excel, and Outlook. What We Offer • 100% remote position with a flexible schedule (Mon - Fri) or (Wed - Sun) • Competitive salary and performance-based incentives. • Full benefits package, including: • Medical, dental, and vision coverage. • 401(k) with employer contributions. • Paid time off, personal days, and holidays. • Life and disability insurance. • Ongoing training and career development. Job Type: Full-time Pay: $90,000.00 - $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: • MCG Guidelines: 1 year (Preferred) • Utilization Management Pre-Service: 1 year (Required) • Utilization management with a Managed Care Plan: 1 year (Required) • CMS Guidelines: 1 year (Preferred) • Medicare Advantage: 1 year (Preferred) License/Certification: • CALIFORNIA RN or LVN License (Required) Work Location: Remote Apply tot his job Apply tot his job
