Case Manager RN

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  • 19-00417
  • Full Time/Contract
  • Recruiting
  • Pasadena, CA
Job Description
UM Review Nurse – RN
(Managed Care/Medical Group)

The Utilization Nurse is responsible to assure health care services are available to Medical Group members in an appropriate cost-effective manner and delivery of those services to promote healthy outcomes.

  • Provides first level clinical review for all outpatient, planned inpatient and ancillary services requiring authorization. Performs retrospective chart review as indicated.
  • Utilizes decision-making and critical-thinking skills in the review and determination of coverage for medically necessary health care services.
  • Refers those requests that do not meet medical criteria review to the Medical Director or Physician Advisor for second level review and determination.
  • Completes data entry and correspondence as necessary for each review.
  • Answers Utilization Management directed telephone calls; managing them in a professional and competent manner.
  • Processes all prior authorizations to completion utilizing appropriate review criteria.
  • Identifies and refers all potential quality issues to the Clinical Quality Management Department, and suspected fraud and abuse cases to Program Integrity.
  • Acts as liaison between the IHHMG members, network providers Provider Relations Department for contracted health plans.
  • Screens and refers appropriate health plan members for short term or complex case management, disease management, or other care management strategies as applicable.
  • Maintains knowledge of and is compliant with current UM Plan and policies & procedures.
  • Performs quality improvement activities and maintains current quality improvement document as directed.
  • Perform other duties as assigned.


  • Current California RN 
  • 3+ years of nursing experience in an acute care hospital setting
  • 3+ years of managed care and utilization review experience
  • Experience with clinical review
  • Spanish speaking or other second language a plus!

$39 – $40.50hr

$42- $48hr

Additional Information
Full-Time, M-F


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