We are recruiting for a Utilization Review Nurse to join a large healthcare organization within the Sacramento region. The Utilization Review Nurse is responsible for overseeing the daily operations of the UM Pre-Authorization team, ensuring referral requests are processed consistently, accurately, and within regulatory timeframes. This position plays a key role in workflow oversight, staff support, regulatory compliance, and collaboration with internal and external partners. The ideal candidate will have 7+ years of UM experience with charge, lead, supervisory, or management responsibilities and experience working with health plan auditors.
- Pay range: $54-$66/hour DOE
- Hybrid
- License Required: Registered Nurse – CA
- 6-month contract role
PRIMARY RESPONSIBILITIES:
- Oversee day-to-day operations of the Pre-Authorization team, ensuring timely response and appropriate evaluation of referral reviews.
- Ensure correct selection and application of clinical criteria and accurate preparation of cases for UM Physician Reviewers when indicated.
- Ensure timely verbal and written documentation and completion of referral files.
- Maintain adequate staffing levels, assign work appropriately, and adjust workflow to meet departmental goals.
- Organize, structure, and chair at least one pre-authorization meeting per month, involving additional staff as appropriate.
- Motivate and coach staff, including new-hire training, problem-solving support, and participation in special projects.
- Assist the Manager with performance activities, including monitoring, coaching, education, and providing feedback to team members.
- Develop a Pre-Authorization team that is consistent, knowledgeable, accurate, and committed to meeting timelines.
- Ensure UM Physicians receive all relevant information needed for accurate referral review.
- Foster strong working relationships between the Pre-Authorization team, the Medical Director, and Physician Reviewers.
- Promote appropriate application of clinical criteria, policies, and guidelines to prior-authorization referrals.
- Participate in audit preparation and serve as a resource during health plan audits.
- Monitor, compile, analyze, and report UM data, trends, and performance metrics.
SKILLS & QUALIFICATIONS:
- Graduate of an accredited school of nursing.
- Registered Nurse (CA) license required.
- Bachelor’s degree in Nursing or equivalent experience required.
- 5+ years of clinical nursing experience required.
- 3+ years of utilization management experience in a health plan, UM operations, acute care, or subacute utilization review required.
- Demonstrated leadership and management skills.
- Knowledge of applicable federal/state regulations and accreditation standards.
- Working knowledge of UM review processes and regulatory requirements.
- Ability to monitor, compile, analyze, and report data/statistics.
- Excellent interpersonal, written, and verbal communication skills.
- Demonstrated ability to lead, mentor, and develop staff.
- Ability to work effectively with all levels of the organization and external partners.
- Proficiency with Microsoft Office (Word, Excel) and other clinical/administrative systems.