Must have direct experience in: * Concurrent Review & Inpatient Utilization Management * Discharge Planning & Transitions of Care * Utilizing InterQual, MCG, and CMS Guidelines * Technical Skills:
Must have direct experience in: * Concurrent Review & Inpatient Utilization Management * Discharge Planning & Transitions of Care * Utilizing InterQual, MCG, and CMS Guidelines * Technical Skills:
Utilization Management - RN
Sunnyvale, CA · On-site
Escalate complex medical necessity cases to the Medical Director. * Educate providers on utilization management policies and review criteria. * Document all reviews and clinical decisions accurately ...
Quick apply
Utilization Management - RN
Sunnyvale, CA · On-site
Escalate complex medical necessity cases to the Medical Director. * Educate providers on utilization management policies and review criteria. * Document all reviews and clinical decisions accurately ...
Utilization Management - RN
Sunnyvale, CA · On-site
Escalate complex medical necessity cases to the Medical Director. * Educate providers on utilization management policies and review criteria. * Document all reviews and clinical decisions accurately ...
Utilization Management - RN
Sunnyvale, CA · On-site
Escalate complex medical necessity cases to the Medical Director. * Educate providers on utilization management policies and review criteria. * Document all reviews and clinical decisions accurately ...
Utilization Management - RN
Sunnyvale, CA · On-site
Escalate complex medical necessity cases to the Medical Director. * Educate providers on utilization management policies and review criteria. * Document all reviews and clinical decisions accurately ...
Utilization Management - RN
Sunnyvale, CA · On-site
Escalate complex medical necessity cases to the Medical Director. * Educate providers on utilization management policies and review criteria. * Document all reviews and clinical decisions accurately ...
Utilization Management - RN
Sunnyvale, CA · On-site
Escalate complex medical necessity cases to the Medical Director. * Educate providers on utilization management policies and review criteria. * Document all reviews and clinical decisions accurately ...
Quick apply
Utilization Management - RN
Sunnyvale, CA · On-site
Escalate complex medical necessity cases to the Medical Director. * Educate providers on utilization management policies and review criteria. * Document all reviews and clinical decisions accurately ...
Utilization Management - RN
Sunnyvale, CA · On-site
Escalate complex medical necessity cases to the Medical Director. * Educate providers on utilization management policies and review criteria. * Document all reviews and clinical decisions accurately ...
Utilization Management - RN
Sunnyvale, CA · On-site
Escalate complex medical necessity cases to the Medical Director. * Educate providers on utilization management policies and review criteria. * Document all reviews and clinical decisions accurately ...
Utilization Management RN
Bakersfield, CA · Remote
$57.37 - $85.33/hr
... Director as needed. * Ensure compliance with turnaround times and accuracy standards are met ... Previous inpatient Utilization Management (UM) experience strongly preferred * Experience with MCG ...
Utilization Management RN
Bakersfield, CA · Remote
$57.37 - $85.33/hr
... Director as needed. * Ensure compliance with turnaround times and accuracy standards are met ... Previous inpatient Utilization Management (UM) experience strongly preferred * Experience with MCG ...
Utilization Management RN
Bakersfield, CA · On-site
... Director as needed. * Ensure compliance with turnaround times and accuracy standards are met ... Previous inpatient Utilization Management (UM) experience strongly preferred * Experience with MCG ...
Utilization Management RN
Bakersfield, CA · On-site
... Director as needed. * Ensure compliance with turnaround times and accuracy standards are met ... Previous inpatient Utilization Management (UM) experience strongly preferred * Experience with MCG ...
Utilization Management RN
Bakersfield, CA · Remote
$57.37 - $85.33/hr
... Director as needed. * Ensure compliance with turnaround times and accuracy standards are met ... Previous inpatient Utilization Management (UM) experience strongly preferred * Experience with MCG ...
Utilization Management RN
Bakersfield, CA · Remote
$57.37 - $85.33/hr
... Director as needed. * Ensure compliance with turnaround times and accuracy standards are met ... Previous inpatient Utilization Management (UM) experience strongly preferred * Experience with MCG ...
Utilization Management RN
Bakersfield, CA · On-site +1
$57.37 - $85.33/hr
... Director as needed. * Ensure compliance with turnaround times and accuracy standards are met ... Previous inpatient Utilization Management (UM) experience strongly preferred * Experience with MCG ...
Utilization Management RN
Bakersfield, CA · On-site +1
$57.37 - $85.33/hr
... Director as needed. * Ensure compliance with turnaround times and accuracy standards are met ... Previous inpatient Utilization Management (UM) experience strongly preferred * Experience with MCG ...
The Utilization Management Manager will report to the Director of Utilization Management. In this role you will lead and support a team of clinicians to ensure safe, timely, and appropriate care for ...
The Utilization Management Manager will report to the Director of Utilization Management. In this role you will lead and support a team of clinicians to ensure safe, timely, and appropriate care for ...
The Utilization Management Manager will report to the Director of Utilization Management. In this role you will lead and support a team of clinicians to ensure safe, timely, and appropriate care for ...
The Utilization Management Manager will report to the Director of Utilization Management. In this role you will lead and support a team of clinicians to ensure safe, timely, and appropriate care for ...
The Utilization Management Manager will report to the Director of Utilization Management. In this role you will lead and support a team of clinicians to ensure safe, timely, and appropriate care for ...
The Utilization Management Manager will report to the Director of Utilization Management. In this role you will lead and support a team of clinicians to ensure safe, timely, and appropriate care for ...
The Utilization Management Manager will report to the Director of Utilization Management. In this role you will lead and support a team of clinicians to ensure safe, timely, and appropriate care for ...
The Utilization Management Manager will report to the Director of Utilization Management. In this role you will lead and support a team of clinicians to ensure safe, timely, and appropriate care for ...
The Utilization Management Manager will report to the Director of Utilization Management. In this role you will lead and support a team of clinicians to ensure safe, timely, and appropriate care for ...
The Utilization Management Manager will report to the Director of Utilization Management. In this role you will lead and support a team of clinicians to ensure safe, timely, and appropriate care for ...
The Utilization Management Manager will report to the Director of Utilization Management. In this role you will lead and support a team of clinicians to ensure safe, timely, and appropriate care for ...
The Utilization Management Manager will report to the Director of Utilization Management. In this role you will lead and support a team of clinicians to ensure safe, timely, and appropriate care for ...
The Utilization Management Manager will report to the Director of Utilization Management. In this role you will lead and support a team of clinicians to ensure safe, timely, and appropriate care for ...
The Utilization Management Manager will report to the Director of Utilization Management. In this role you will lead and support a team of clinicians to ensure safe, timely, and appropriate care for ...
Utilization Management RN
Bakersfield, CA · Remote
... Director as needed. * Ensure compliance with turnaround times and accuracy standards are met ... Previous inpatient Utilization Management (UM) experience strongly preferred * Experience with MCG ...
Utilization Management RN
Bakersfield, CA · Remote
... Director as needed. * Ensure compliance with turnaround times and accuracy standards are met ... Previous inpatient Utilization Management (UM) experience strongly preferred * Experience with MCG ...
Utilization Management RN
Bakersfield, CA · On-site
$57.37 - $85.33/hr
... Director as needed. * Ensure compliance with turnaround times and accuracy standards are met ... Previous inpatient Utilization Management (UM) experience strongly preferred * Experience with MCG ...
New
Utilization Management RN
Bakersfield, CA · On-site
$57.37 - $85.33/hr
... Director as needed. * Ensure compliance with turnaround times and accuracy standards are met ... Previous inpatient Utilization Management (UM) experience strongly preferred * Experience with MCG ...
New
The Utilization Management Manager will report to the Director of Utilization Management. In this role you will lead and support a team of clinicians to ensure safe, timely, and appropriate care for ...
The Utilization Management Manager will report to the Director of Utilization Management. In this role you will lead and support a team of clinicians to ensure safe, timely, and appropriate care for ...
Director Utilization Management information
What are the key skills and qualifications needed to thrive in the director utilization management position, and why are they important?
To thrive as a Director Utilization Management, you need a strong background in healthcare administration, case management, and data-driven decision-making, often supported by a clinical degree and several years of management experience. Familiarity with utilization management software, electronic health records (EHRs), and certifications such as CCM or ACM are typically valued. Exceptional leadership, communication, and problem-solving skills distinguish top performers in this role. These competencies are vital for optimizing resource use, ensuring regulatory compliance, and leading teams to meet quality care standards.
What is a director utilization management?
A Director of Utilization Management oversees the review and approval of medical services to ensure they are necessary, efficient, and cost-effective. They develop strategies to improve care quality while managing healthcare costs, working closely with providers, payers, and regulatory bodies. Their responsibilities include policy development, compliance with healthcare regulations, and leading a team of utilization review professionals. This role is common in hospitals, insurance companies, and managed care organizations.
What are the typical daily responsibilities of a director utilization management?
A Director Utilization Management generally oversees a team responsible for reviewing patient care to ensure appropriate resource use and compliance with payer requirements. Daily tasks may include analyzing utilization data, developing policy and process improvements, collaborating with clinical and administrative staff, and addressing escalated cases or issues. Directors frequently attend strategy meetings, conduct staff training, and engage with external partners like insurance providers. This role requires balancing administrative oversight with hands-on problem solving to support both cost efficiency and quality patient care.
What are the most commonly searched types of Utilization Management jobs in California? The most popular types of Utilization Management jobs in California are:
What are popular job titles related to Director Utilization Management jobs in California? For Director Utilization Management jobs in California, the most frequently searched job titles are:
- Director Of Nursing
- Senior Cvs Health Utilization Management
- Utilization Management Nurse
- Work From Home No Experience Utilization Management Nurse
- Care Network Healthcare Management Group
- Remote Cvs Utilization Management Nurse
- Remote Ncqa Accreditation
- Director Medical Ai Trainer
- Utilization Management Nurse Consultant
- Remote Utilization Management
What job categories do people searching Director Utilization Management jobs in California look for? The top searched job categories for Director Utilization Management jobs in California are:
What cities in California are hiring for Director Utilization Management jobs? Cities in California with the most Director Utilization Management job openings:
Full-time
Posted 15 days ago
Job description
We are seeking a Registered Nurse (RN) to join our Utilization Management team. In this role, you will perform concurrent reviews, prior authorizations, medical necessity reviews, discharge planning, and transitions of care. You will collaborate closely with physicians, hospitals, and interdisciplinary teams to ensure members receive appropriate, cost-effective, and evidence-based care.
This position is ideal for an RN with a strong acute care background and proven experience in managed care and utilization management.
Key Responsibilities- Utilization Reviews: Perform concurrent, prior authorization, and retrospective utilization reviews.
- Guideline Application: Evaluate medical necessity using InterQual, MCG, CMS, and LCD/NCD guidelines.
- Care Coordination: Coordinate discharge planning and seamless transitions of care with providers and healthcare facilities.
- Interdisciplinary Collaboration: Work alongside physicians, hospital staff, specialists, and internal care management teams.
- Documentation & Escalation: Request and review additional clinical documentation as needed; escalate complex medical necessity cases to the Medical Director.
- Provider Education: Educate providers on utilization management policies and review criteria.
- Compliance & Quality: Accurately document all reviews and decisions within medical management systems while identifying care gaps and supporting quality improvement initiatives.
- Licensure: Active Registered Nurse (RN) license (ability to obtain multi-state licensure if needed).
- Education: Graduate of an accredited School of Nursing.
- Clinical Experience: Minimum 4 years of clinical nursing experience.
- Managed Care Experience: Minimum 2 years of managed care or HMO experience (Medicare Advantage experience required).
- Core Expertise: Must have direct experience in:
- Concurrent Review & Inpatient Utilization Management
- Discharge Planning & Transitions of Care
- Utilizing InterQual, MCG, and CMS Guidelines
- Technical Skills: Proficiency with medical management software and Microsoft Office Suite.
- Soft Skills: Strong critical thinking, excellent communication, and exceptional organizational skills.
- Bachelor of Science in Nursing (BSN).
- Clinical background in Emergency Department (ER) or Intensive Care Unit (ICU).
- Case Management experience.
- Prior Utilization Management experience directly within a health plan or managed care organization.
- Experience working directly with hospitals, physicians, and provider networks.
- Strong clinical judgment and confidence in making accurate medical necessity determinations.
- Ability to comfortably navigate challenging conversations regarding levels of care.
- High organizational skills to manage multiple dynamic cases simultaneously in a fast-paced managed care environment.
- A detail-oriented mindset committed to high-quality patient outcomes.