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Clinical Review Rn Jobs in California (NOW HIRING)

Prime Healthcare

Utilization Review RN

Ontario, CA · On-site

$71K - $104K/yr

The methodology is designed to facilitate and insure the achievement of quality, clinical and cost ... Minimum 3 years RN Utilization Manager working for a Health Plan. * At least 3 years of experience ...

Prime Healthcare

Utilization Review RN

Ontario, CA · On-site

$71K - $104K/yr

The methodology is designed to facilitate and insure the achievement of quality, clinical and cost ... Minimum 3 years RN Utilization Manager working for a Health Plan. * At least 3 years of experience ...

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Clinical Review Rn information

What is a clinical review RN?

Clinical Review RNs, or Clinical Review Registered Nurses, are licensed nurses who evaluate medical records, treatment plans, and health care documentation to ensure that patient care meets established standards and guidelines. They play a critical role in reviewing the medical necessity, appropriateness, and efficiency of healthcare services provided to patients. Clinical Review RNs often work for insurance companies, hospitals, or healthcare organizations to help with utilization management, case review, and quality assurance. Their expertise helps improve patient outcomes and manage healthcare costs by ensuring the right care is delivered at the right time.

What skills and qualifications are needed to thrive as a clinical review RN?

To thrive as a Clinical Review RN, you need a robust clinical nursing background, strong assessment skills, and an active RN license, often with experience in case management or utilization review. Familiarity with utilization management software, electronic health records, and knowledge of insurance regulations or CMS guidelines is typically required. Excellent communication, critical thinking, and attention to detail help set outstanding Clinical Review RNs apart. These skills ensure accurate clinical evaluations, compliance with regulations, and effective coordination between patients, providers, and payers.

How does a clinical review RN collaborate with other healthcare professionals during the patient care review process?

A Clinical Review RN regularly works with physicians, case managers, social workers, and insurance representatives to assess the medical necessity and appropriateness of patient care plans. They participate in interdisciplinary meetings, provide clinical insights, and help ensure that care decisions align with policies and regulations. This collaboration is key to streamlining the review process, minimizing delays in patient care, and supporting optimal outcomes for both patients and the healthcare organization.

What is the difference between Clinical Review Rn vs Medical Reviewer?

AspectClinical Review RnMedical Reviewer
CredentialsRegistered Nurse (RN) license, clinical experienceMedical degree (MD or DO), specialized training
Work EnvironmentHealthcare facilities, insurance companies, telehealthHospitals, insurance companies, consulting firms
Employer & Industry UsageInsurance, healthcare providers, government agenciesInsurance, legal, healthcare consulting
Primary FocusAssessing medical records, determining coverage eligibilityEvaluating medical cases, providing expert opinions

While both roles involve reviewing medical information, Clinical Review Rns primarily assess insurance claims and medical records as registered nurses, whereas Medical Reviewers are typically physicians with advanced medical training who evaluate complex cases and provide expert opinions. Understanding these differences helps in choosing the right career path or job search focus.

How to become a clinical review RN?

To become a clinical review RN, you typically need to earn a Bachelor of Science in Nursing (BSN) or an associate degree in nursing, pass the NCLEX-RN exam to obtain licensure, and gain clinical experience in healthcare settings. Additional certifications in case management or utilization review can enhance qualifications for this role.

What does a clinical review RN do?

A clinical review RN evaluates medical records, treatment plans, and patient data to determine coverage, appropriateness, and compliance with healthcare policies. They often work for insurance companies or healthcare organizations, requiring strong clinical knowledge, attention to detail, and certification such as a registered nurse license. Their assessments help ensure proper patient care and cost-effective treatment decisions.
Clinical Review Rn jobs near you
Infographic showing various Clinical Review Rn job openings in California as of August 2026, with employment types broken down into 17% As Needed, and 83% Full Time. Highlights an 83% In-person, and 17% Remote job distribution.

Utilization Review RN (Hybrid)

Daly City, CA • On-site

Vivo HealthStaff
Health Care and Social Assistance • 11 - 50 employees
Learn more about Vivo HealthStaffexternal

Full-time

Re-posted 29 days ago

Key responsibilities

  • Performs concurrent and retrospective medical record reviews to assess medical necessity and service authorization.

  • Collaborates with healthcare team members and third-party payers to facilitate appropriate care and manage denials.

  • Communicates utilization plans, obtains authorizations, and documents all activities related to resource utilization and compliance.

Job description

Vivo HealthStaff is searching for a Utilization Review RN for a hybrid position for a health plan in San Francisco. It is a hybrid position with 1-2 days per week on-site required.Collaborates with the physician, nurse case manager, social worker, and other members of the health care team to meet individualized patient outcomes. Performs concurrent, and retrospective medical record reviews based on approved screening criteria, knowledge of insurance coverage, and communication with the third-party payers. Ensures medical necessity determinations, service authorization and concurrent denials are managed effectively and financially responsibly.EducationValid RN license in State of CaliforniaBachelor's degree in NursingExperienceClinical experience in acute care setting RequiredExperience with interqual and millimen PreferredLicenses and CertificationsCPR - Cardiac Pulmonary Resuscitation CPR/BLS Preferred andCCM - Certified Case Manager CCM Preferred andACMA PreferredKnowledge, Skills, and AbilitiesVerbal and written communication skills.Basic computer skills.Diagnostic and problem-solving skills.Contributes to the achievement of established department goals and objectives and adheres to department policies, procedures, quality standards, and safety standards. Complies with governmental and accreditation regulations.Actively participates in ongoing professional enrichment and educational opportunities. Collaborates with and assists the nurse case manager and social worker to meet the patients' continuing health needs in a high quality, cost effective manner. Participates in planning rounds as needed to address and communicate issues related to acuity level of patient, LOS insurance and discharge needs.Collects quality improvement data in accordance with approved indicators. Recognizes potential problems and makes referrals to quality improvement, risk management, safety, infection control, and other departments as appropriate.Confers and collaborates routinely with the physician advisor, division chiefs, and attending physicians to resolve problems regarding acuity and level of care.Evaluates concurrent and retrospective denials for appeal opportunities. May generate appeal letters based on knowledge of clinical severity and intensity.Identifies insurance information, obtains authorization, communicates with financial counseling and assigns appropriate length of stay for admission.Implements strategies to avoid denials including potential denial notification to attending physician. Issues letter of non-coverage for Medicare or third party payers according to policies and procedures. Communicates utilization plans to case management team.Performs admission reviews and subsequent concurrent reviews to determine the necessity for acute care by application of accepted criteria based on age specific needs. Interacts with and assists third party payer reviewers to facilitate appropriate care and ensure payment for services. Performs concurrent and retrospective reviews telephonically as required. Completes all forms and documentation necessary to support appropriate utilization of resources.Serves as a resource to all staff in areas of utilization review/management. Educates members of health care team through in-services, staff meetings, orientation and formal educational offerings.Demonstrates knowledge of the dynamics of abuse/neglect, including identification and reporting laws. Coordinates with investigating law enforcement, protection agencies, hospital security, risk management, and healthcare team. Demonstrates knowledge of community resources serving the high social risk populations.Performs other duties as assigned.

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About Vivo HealthStaff

Sourced by ZipRecruiter

Vivo HealthStaff provides permanent recruitment services for both clinical and administrative positions in the healthcare sector. Over the past 2 years, our clients have seen a 98% retention rate with Vivo HealthStaff placements.

Industry

Health care and social assistance

Company size

11 - 50 Employees

Headquarters location

Dublin, CA, US

Year founded

2016

Social media

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