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
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.
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
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
Experience in Managed Care, Health Plans, or payer-side healthcare operations
Familiarity with NCQA standards
Previous case management or care coordination experience
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