Job Description:
• Evaluate requested services against benefit language, medical policy, and nationally recognized criteria such as MCG and NCCN
• Determine the appropriate level of care while applying state and federal requirements
• Route cases that do not meet criteria to the Medical Director for secondary clinical review
• Ensure adverse determinations are timely, defensible, and aligned with NCQA/URAC accreditation standards
• Analyze clinical documentation for completeness and identify acuity, risk indicators, inconsistencies, and gaps
• Conduct outreach or escalation when documentation issues are identified
• Manage caseloads according to urgency, regulatory deadlines, and member impact
• Confirm eligibility, benefits, authorization, and network status
• Steer members toward in-network, benefit-compliant options when clinically appropriate
• Prepare clinical summaries and documentation for appeals
• Coordinate peer-to-peer discussions with physicians and route appeals, including IRO referrals
• Document reviews, rationales, criteria citations, and outcomes in UM systems in real time
• Meet productivity, quality, accuracy, and turnaround standards
• Participate in calibration activities and apply feedback
• Maintain HIPAA compliance and complete required training and annual competencies
• Cross-train and provide coverage support as needed
Requirements:
• Current, unrestricted RN license in the United States or a U.S. territory; compact license accepted where applicable
• Graduate of an accredited nursing program; ADN or diploma required, BSN preferred
• 1–2+ years of recent clinical experience in acute care, med-surg, ICU/ED, or similar setting
• Utilization review/utilization management experience preferred
• Proficiency with Microsoft Word, Excel, and Outlook
• Working knowledge of ICD-10, CPT, and HCPCS coding and medical claims
• Ability to interpret medical records and apply evidence-based criteria and plan medical policies
• Comfort working across multiple screens and systems with strong typing proficiency
• Ability to work independently within UM platforms and workflows after training
• Ability to work Monday–Friday, 8:00 AM–5:00 PM Pacific Time, with rotating Saturday coverage as required
• HIPAA compliance and confidentiality using minimum-necessary standards
Benefits:
• Competitive base salary
• Comprehensive medical and dental through our own health solutions
• Paid Time Off
• Mental health support
• Retirement planning
• Financial protection
• Professional development with clear career progression and learning budgets
• Mission-driven culture where diverse perspectives drive real impact
• Wellness programs
• Other employee perks
• Full benefits package effective day one