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Utilization Management (Remote) California License

Long Beach, CA

Job Title: Care Review Clinician II (RN or LVN) – Remote
Location: Remote (Must have active CA license and be available during Pacific Standard Time hours)
Pay Rate: Up to $45/hour
Job Type: Temp-to-Perm


About the Role:

A leading Managed Care Organization is seeking an experienced and detail-oriented Care Review Clinician II (RN or LVN) to join their Utilization Management team. This remote position plays a key role in reviewing clinical service requests, supporting continuity of care, and ensuring appropriate, cost-effective healthcare decisions are made in compliance with regulatory and clinical guidelines.


Key Responsibilities:

  • Perform clinical reviews of service requests including concurrent and prior authorization determinations

  • Serve as clinical support to the Continuity of Care (COC) and Community Support teams

  • Determine whether requests meet COC or community support criteria and escalate for MD review when needed

  • Conduct provider outreach as appropriate to support authorizations and care coordination

  • Utilize InterQual and other clinical guidelines to assess medical necessity and appropriate length of stay

  • Ensure documentation meets compliance, quality, and turnaround standards

  • Create and manage authorizations in accordance with established UM processes

  • Participate in team meetings and collaborate with other departments to support member care


Required Qualifications:

  • Active, unrestricted LVN or RN license in California

  • 3–5 years of clinical experience (inpatient, outpatient, or hospital setting strongly preferred)

  • Prior experience in Utilization Management, Concurrent Review, or Prior Authorization

  • Strong analytical and critical thinking skills in a fast-paced, metric-driven environment

  • Solid computer proficiency, including ability to toggle between multiple databases and tools

  • Experience using InterQual or similar medical necessity criteria tools

  • Knowledge of HIPAA and regulatory compliance standards

  • Excellent verbal and written communication skills


Preferred Qualifications:

  • Experience in Managed Care, Health Plans, or payer-side healthcare operations

  • Familiarity with NCQA standards

  • Previous case management or care coordination experience


Additional Information:

  • Must provide your own secure and quiet workspace for remote work

  • Equipment (laptop, monitors, etc.) will be provided by the organization

  • Must be available to work 8-hour shifts during PST business hours, Monday–Friday

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