Clinical Utilization Review Nurse

11 hours ago


Corona, California, United States KPC Global MSO Full time
Job Summary

We are seeking a skilled Clinical Utilization Review Nurse to join our team at KPC Global MSO. As a key member of our Utilization Review and Case Management Department, you will play a critical role in ensuring the quality and efficiency of our medical management services.

Key Responsibilities
  • Coordinate and review medical records to assess adherence to admission and treatment criteria
  • Participate in Case Management and Treatment Team meetings to ensure seamless communication and collaboration
  • Provide education and training to healthcare professionals on utilization review and case management best practices
  • Review patient charts to identify areas for improvement and implement changes to optimize care
  • Communicate with fiscal intermediaries, patients, and families to ensure timely and accurate referral determinations
Requirements
  • CA LVN license required; CA RN license preferred
  • Bachelor's or Master's degree in Social Work, behavioral or mental health, nursing, or related field preferred
  • 3-5 years of acute care experience; 2 years of managed care experience in UM/CM Department preferred
  • Knowledge of CMS, State Regulations, URAC, and NCQA guidelines preferred
What We Offer

KPC Global MSO offers a competitive salary and benefits package, as well as opportunities for professional growth and development. If you are a motivated and detail-oriented Clinical Utilization Review Nurse looking for a challenging and rewarding role, we encourage you to apply.



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