Remote Utilization Management Nurse (RN or LVN – CA Lic. Req.) | Preservice/Denials Dept.

Remote Utilization Management Preservice Nurse-Denial Letter Dept. (RN or LVN – California License Required) Contract-to-Permanent Hire | Fully Remote (U.S.) May reside anywhere in the US as long as you have an active California RN or LNV license. A rapidly growing healthcare services organization is seeking a Utilization Management Nurse (RN or LVN) to support pre-service and prior authorization reviews. We are looking for Nurses that have Preservice Review experience along with robust Denial Letter writing experience using clinical rational - not just templates. This role plays a key part in ensuring patients receive appropriate, timely, and cost-effective care while working collaboratively with physicians, care teams, and healthcare providers. This is a 100% remote opportunity open to candidates anywhere in the United States, however an active California RN or LVN license is required. This position begins as a contract role with strong potential for permanent hire based on performance. Schedule:

• Monday - Friday | 8:00 AM – 5:00 PM PST (Preservice Team)
• Sunday - Thursday | 8:00 AM – 5:00 PM PST (Preservice/Denials Team)

Key Responsibilities

• Review prior authorization and pre-service requests for inpatient and outpatient care.
• Develop and issue custom denial letters that clearly articulate clinical rationale, using member-specific documentation and evidence-based criteria (e.g., MCG, InterQual, CMS guidelines).
• Ensure denial determinations are well-supported, compliant, and audit-ready, avoiding reliance on templated language.
• Analyze clinical records and documentation to support accurate, defensible coverage decisions.
• Evaluate medical necessity using clinical guidelines such as MCG, InterQual, or comparable evidence-based criteria.
• Collaborate with physicians, providers, case managers, and medical directors to support care determinations.
• Verify patient eligibility, benefits, and accuracy of medical coding (ICD-10, CPT).
• Ensure requests are processed within required turnaround times while maintaining accurate documentation.
• Provide clinical input for appeals and grievance reviews when necessary.
• Communicate professionally with providers, patients, and internal teams regarding care decisions.
• Assist with single-case agreements or out-of-network service reviews when applicable.
• Participate in team meetings, case discussions, and quality improvement initiatives.

Required Qualifications

• Active, unrestricted California RN or LVN license
• Minimum 1 year of Medicare experience
• Experience or familiarity with utilization management, prior authorization, or clinical review
• Understanding of medical terminology, coding (ICD-10/CPT), and CMS guidelines
• Strong critical thinking and clinical decision-making skills
• Excellent written and verbal communication
• Ability to manage multiple requests and meet deadlines in a fast-paced environment
• Proficiency with Microsoft Office (Word, Excel, Outlook)

Preferred Qualifications

• 2+ years of experience in utilization management, managed care, or hospital settings
• Experience using MCG (Milliman), InterQual, or similar clinical guidelines
• Familiarity with Medicare Managed Care Plans

Compensation & Benefits

• Contract-to-Permanent Hire Opportunity
• 100% Remote Work Environment
• Medical, dental, and vision insurance
• 401(k) with employer contributions
• Professional development and training opportunities

Apply today if you're a licensed California RN or LVN looking for a remote role in utilization management with long-term career potential. Equal Opportunity Employer We are an Equal Opportunity Employer and are committed to fostering a diverse and inclusive workplace. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, gender identity, sexual orientation, pregnancy, national origin, age, disability, genetic information, veteran status, or any other characteristic protected by applicable federal, state, or local laws. Job Type: Full-time Pay: $100,000.00 - $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

Application Question(s):

• Have you worked for a health plan that services Medicare members?
• Do you have experience independently writing denial letters using clinical rationale (not relying solely on templates)?

Experience:

• CMS Guidelines: 1 year (Preferred)
• Medicare: 1 year (Required)
• Preservice/Prior Authorization: 1 year (Required)

Language:

• Fluent Spanish (Preferred)

License/Certification:

• unexpired CALIFORNIA RN or LVN License (Required)

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