Job Description
Position Overview
The Utilization Review Nurse is responsible for coordinating care and ensuring the medical necessity and appropriateness of services through effective communication, clinical review, and adherence to regulatory and organizational guidelines. This role works collaboratively with providers and internal departments to support timely, compliant, and high-quality patient care outcomes.
Key Responsibilities
+ Serve as a primary point of contact for contracted providers and internal staff, ensuring clear and timely communication regarding care coordination, referrals, and organizational policies and procedures.
+ Collaborate with Member Services and Provider Relations to address quality of care concerns and grievance cases, facilitating timely and effective resolution.
+ Review and process referrals for Durable Medical Equipment (DME), home health, and outpatient services, applying clinical guidelines and Medi-Cal criteria to determine medica...
The Utilization Review Nurse is responsible for coordinating care and ensuring the medical necessity and appropriateness of services through effective communication, clinical review, and adherence to regulatory and organizational guidelines. This role works collaboratively with providers and internal departments to support timely, compliant, and high-quality patient care outcomes.
Key Responsibilities
+ Serve as a primary point of contact for contracted providers and internal staff, ensuring clear and timely communication regarding care coordination, referrals, and organizational policies and procedures.
+ Collaborate with Member Services and Provider Relations to address quality of care concerns and grievance cases, facilitating timely and effective resolution.
+ Review and process referrals for Durable Medical Equipment (DME), home health, and outpatient services, applying clinical guidelines and Medi-Cal criteria to determine medica...