Utilization Management RN – Inpatient Review

About the role

The Utilization Management Nurse reviews inpatient stays, applies national care level guidelines, and ensures appropriate discharge planning. Reporting to the Utilization Management Nurse Manager, you will evaluate clinical information to determine medical necessity and coordinate higher‑level care when needed.

Key responsibilities

• Perform prospective, concurrent, and retrospective utilization reviews using BSC and CMS evidence‑based guidelines.
• Determine first‑level approvals and ensure discharge planning aligns with member acuity and post‑acute needs.
• Prepare and present cases to the Medical Director for oversight and communicate determinations to providers.
• Develop member‑centered documentation that complies with regulatory and accreditation standards.
• Identify quality‑of‑care issues, intervene clinically, and refer acute inpatient needs to Case Management.
• Participate in staff meetings, clinical rounds, and weekly huddles while maintaining productivity metrics.
• Maintain a HIPAA‑compliant workspace for telework.

Required profile

• Associate’s degree in nursing (Bachelor’s preferred).
• Current California nursing license.
• Minimum 5 years of experience in an inpatient hospital setting.

Required skills

What we offer

• Hourly pay range $44.00‑$46.00.
• Overtime eligibility for non‑exempt employees.
• Medical, dental, vision, and HSA options.
• 10 paid days off, 3 days bereavement leave.
• 401(k) with employer match.
• Life and disability insurance.