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Medical Review Rn Jobs in California (NOW HIRING)

Prime Healthcare

Utilization Review RN

Ontario, CA · On-site

$71K - $104K/yr

... the medical record for the medical necessity, intensity of service and severity of illness ... 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

... medical record for the medical necessity, intensity of service and severity of illness ... Minimum 3 years RN Utilization Manager working for a Health Plan. * At least 3 years of experience ...

GQR Global Markets

RN - Case Manager

Mission Viejo, CA · On-site

$2.0K - $2.1K/wk

Registered Nurse (RN) Facility: Estimated Pay: $2065.88 - $2160.88 Duration: 13 weeks Specialty ... Case Management/Utilization Review Shift: Day Benefits: * Day 1 Insurance * Cigna medical, MetLife ...

GQR

RN - Case Manager

Roseville, CA · On-site

$2.4K - $2.5K/wk

Contract - W2 Case Management/Utilization Review Registered Nurse (RN) Job Location: Roseville ... Benefits: * Day 1 Insurance * Cigna medical, MetLife dental and vision insurance * License ...

GQR

RN - Case Manager

Oakland, CA · On-site

$2.5K - $2.6K/wk

Contract - W2 Case Management/Utilization Review Registered Nurse (RN) Job Location: Oakland ... Benefits: * Day 1 Insurance * Cigna medical, MetLife dental and vision insurance * License ...

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Medical Review Rn information

What is a Medical Review RN?

A Medical Review RN is a registered nurse who specializes in reviewing medical records and claims to ensure they meet established guidelines and standards. These nurses often work for insurance companies, government agencies, or healthcare organizations, evaluating the necessity, appropriateness, and efficiency of healthcare services provided to patients. Their role may include determining medical necessity, performing utilization reviews, and supporting appeals or audits. They use their clinical knowledge to interpret complex medical information and collaborate with healthcare providers to support accurate decision-making.

How does a Medical Review RN collaborate with other healthcare professionals during the review process?

A Medical Review RN often works closely with physicians, case managers, and insurance representatives to ensure that medical claims and treatment plans meet regulatory and clinical guidelines. Collaboration may involve participating in interdisciplinary meetings, discussing complex cases, and providing clinical expertise to support utilization management decisions. Effective communication and teamwork are essential, as you'll need to relay findings, request additional information, and sometimes clarify medical necessity with providers. This collaborative environment helps ensure quality care for patients while maintaining compliance with payer policies.

What are the key skills and qualifications needed to thrive as a Medical Review RN, and why are they important?

To thrive as a Medical Review RN, you need a strong clinical background, critical thinking skills, and an active RN license, often supported by experience in case management or utilization review. Familiarity with medical coding, claims management software, and knowledge of regulatory guidelines such as Medicare and Medicaid are typically required. Strong attention to detail, excellent written communication, and the ability to work independently are essential soft skills for this role. These competencies ensure accurate and compliant medical record reviews, which are critical for proper claims adjudication and regulatory adherence.

How to become a medical review RN?

To become a medical review RN, you need to earn a nursing license by completing an accredited nursing program and passing the NCLEX-RN exam. Additionally, gaining experience in clinical settings and obtaining certifications such as Certified Professional Coder (CPC) or specialized training in medical review can enhance qualifications for this role.

What cities in California are hiring for Medical Review Rn jobs?

Cities in California with the most Medical Review Rn job openings:

Medical Review Rn jobs near you
Infographic showing various Medical Review Rn job openings in California as of August 2026, with employment types broken down into 1% As Needed, 81% Full Time, 12% Part Time, and 6% Contract. Highlights an 89% Physical, 1% Hybrid, and 10% Remote job distribution.

Utilization Review RN

Ontario, CA • On-site

Prime Healthcare Management Inc
Hospitals • 10K+ employees
Learn more about Prime Healthcare Management Incexternal

$71K - $104K/yr

Full-time

Medical, Dental, Vision, Retirement, PTO

Re-posted 13 days ago

Prime Healthcare rating

6.4

Company rating: 6.4 out of 10

Based on 289 frontline employees who took The Breakroom Quiz

Job description

Overview
Prime Healthcare is an award-winning health system headquartered in Ontario, California. Prime Healthcare operates 54 hospitals and has more than 360 outpatient locations in 15 states providing more than 3.0million patient visits annually. It is one of the nation's leading health systems with over 60,000 employees and physicians. Twenty-one of the Prime Healthcare hospitals are members of the Prime Healthcare Foundation, a 501(c)(3) not-for-profit public charity. Prime Healthcare is actively seeking new members to join our corporate team!
Responsibilities
Responsible for the quality and resource management of all authorizations and referrals with the Prime Healthcare Employee EPO. Works on behalf of the advocate, promoting cost containment and demonstrates leadership to integrate the health care providers to achieve a perceived seamless delivery of care. The methodology is designed to facilitate and insure the achievement of quality, clinical and cost-effective outcomes and to perform a holistic and comprehensive review of the medical record for the medical necessity, intensity of service and severity of illness.
Qualifications
EDUCATION, EXPERIENCE, TRAINING
Required qualifications:
  1. Minimum 7 years Post Graduate of an accredited school of nursing and a current state Registered Nurse license.
  2. Minimum 3 years RN Utilization Manager working for a Health Plan.
  3. At least 3 years of experience in utilization review, referrals, authorizations, denials and appeals.
  4. Current BCLS (AHA) certificate upon hire and maintain current.
  5. Knowledge of MCG Criteria and/or InterQual Criteria required.
  6. Experience and knowledge in basic to intermediate computer skills.

Preferred qualifications:
  1. Five years acute care nursing experience preferred.
  2. Experience with self-funded health plan preferred.

Pay Transparency
Prime Healthcare offers competitive compensation and a comprehensive benefits package that provides employees the flexibility to tailor benefits according to their individual needs. Our Total Rewards package includes, but is not limited to, paid time off, a 401K retirement plan, medical, dental, and vision coverage, tuition reimbursement, and many more voluntary benefit options. Benefits may vary based on employment status, i.e. full-time, part-time, per diem or temporary. A reasonable compensation estimate for this role, which includes estimated wages, benefits, and other forms of compensation, is $71,760.00 to $104,000.00 on an annualized basis. The exact starting compensation to be offered will be determined at the time of selecting an applicant for hire, in which a wide range of factors will be considered, including but not limited to, skillset, years of applicable experience, education, credentials and licensure.
Employment Status
Full Time
Shift
Days
Equal Employment Opportunity
Company is an equal employment opportunity employer. Company prohibits discrimination against any applicant or employee based on race, color, sex, sexual orientation, gender identity, religion, national origin, age (subject to applicable law), disability, military status, genetic information or any other basis protected by applicable federal, state, or local laws. The Company also prohibits harassment of applicants or employees based on any of these protected categories. Know Your Rights: https://www.eeoc.gov/sites/default/files/2022-10/EEOC_KnowYourRights_screen_reader_10_20.pdf

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