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Medical Review Rn Jobs in California (NOW HIRING)

GQR Healthcare

Travel Case Manager RN

Los Angeles, CA · On-site

$2.1K - $2.2K/wk

  • Medical

  • Dental

  • Vision

Travel Contract - W2 Case Management/Utilization Review Registered Nurse (RN) Job Location: Los ... Cigna medical, MetLife dental and vision insurance * License reimbursement for new licenses needed ...

GQR Healthcare

Travel Case Manager RN

Burbank, CA · On-site

$2.0K - $2.1K/wk

  • Medical

  • Dental

  • Vision

Travel Contract - W2 Case Management/Utilization Review Registered Nurse (RN) Job Location: Burbank ... Cigna medical, MetLife dental and vision insurance * License reimbursement for new licenses needed ...

GQR Healthcare

Travel Case Manager RN

Burbank, CA · On-site

$2.1K - $2.2K/wk

  • Medical

  • Dental

  • Vision

Travel Contract - W2 Case Management/Utilization Review Registered Nurse (RN) Job Location: Burbank ... Cigna medical, MetLife dental and vision insurance * License reimbursement for new licenses needed ...

GQR Healthcare

Travel Case Manager RN

Santa Rosa, CA · On-site

$2.0K - $2.1K/wk

  • Medical

  • Dental

  • Vision

Travel Contract - W2 Case Management/Utilization Review Registered Nurse (RN) Job Location: Santa ... Cigna medical, MetLife dental and vision insurance * License reimbursement for new licenses needed ...

GQR Healthcare

Travel Case Manager RN

Torrance, CA · On-site

$2.1K - $2.2K/wk

  • Medical

  • Dental

  • Vision

Travel Contract - W2 Case Management/Utilization Review Registered Nurse (RN) Job Location ... Cigna medical, MetLife dental and vision insurance * License reimbursement for new licenses needed ...

Cedars Sinai

Patient Contact Nurse, RN

Los Angeles, CA

  • Medical

  • Dental

  • Retirement

  • PTO

... medical care in Los Angeles. We also were awarded the Advisory Board Company's Workplace of the ... Participate in PACC huddles, RN escalation reviews, quality assurance processes, and continuous ...

Cedars Sinai

Patient Contact Nurse, RN

Los Angeles, CA · On-site

$45.89 - $73.42/hr

  • Medical

  • Dental

  • Retirement

  • PTO

... medical care in Los Angeles. We also were awarded the Advisory Board Company's Workplace of the ... Participate in PACC huddles, RN escalation reviews, quality assurance processes, and continuous ...

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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.

Appeals & Grievances Nurse

Western Health Advantage

Sacramento, CA • On-site

$95K - $115K/yr

Full-time

Re-posted 24 days ago

Job description

Appeals & Grievances Nurse (RN)
Western Health Advantage
Location: Sacramento, CA (Hybrid)
Job Type: Full-Time, Exempt
Salary: $95,000-$115,000 annually
Travel: Occasional travel required
"Purpose that inspires. Impact that improves lives. Join us in building healthier communities."
Western Health Advantage
Join Our Team
Western Health Advantage (WHA) is seeking an experienced Appeals & Grievances Nurse (RN) to join our Utilization Management team. This role is ideal for a registered nurse with managed care experience who is passionate about ensuring members receive timely, clinically sound, and compliant reviews of appeals and grievances.
Reporting to the Utilization Operations Director, you will collaborate with Medical Directors, Clinical Pharmacists, Appeals & Grievances staff, and contracted provider groups to evaluate complex cases, ensure regulatory compliance, and support exceptional member outcomes.
What You'll Do
As the Appeals & Grievances Nurse, you will:
  • Review medical necessity appeals and grievances requiring clinical evaluation.
  • Research, analyze, and prepare complex appeal cases involving new technology, experimental treatments, transplants, and other specialized services.
  • Determine clinical urgency and provide guidance to the Appeals & Grievances team.
  • Prepare clinical summaries and recommendations for Medical Director review and Appeal Review Meetings.
  • Draft clinical resolution letters for upheld medical necessity determinations.
  • Partner with contracted Medical Groups, hospitals, and providers to coordinate member care and facilitate smooth transitions across the continuum of care.
  • Collaborate with internal departments including Quality Management, Care Management, Member Services, Sales, Marketing, and Wellness on clinical initiatives and special projects.
  • Assist with referrals to Case Management, Disease Management, and Behavioral Health services.
  • Provide care coordination and support for members receiving transgender surgery services.
  • Maintain and update utilization management reference materials, including prior authorization and DME benefit resources.
  • Support regulatory readiness by participating in DMHC, CMS, and NCQA audits, accreditation activities, RFP responses, and Independent Medical Review submissions.
  • Participate in conference calls with regulatory agencies and provide clinical expertise on appeals and grievance cases.
  • Promote compliance with regulatory requirements while ensuring timely, accurate, and member-focused case resolutions.
What You'll Bring
Required Qualifications
  • Bachelor's degree in Nursing (BSN).
  • Active and unrestricted California Registered Nurse (RN) license.
  • 3 years' experience in utilization/case management, discharge planning and/or appeals & grievances in a managed care environment, with increased responsibilities.
  • Strong clinical assessment, critical thinking, and analytical skills.
  • Excellent written and verbal communication skills.
  • Intermediate Microsoft Office skills, including Excel and Word.
  • Certification in Utilization Management (CPHM, CMCN, or equivalent), Quality Management, or Certified Case Manager (CCM).
  • Knowledge of California Department of Managed Health Care (DMHC) regulations.
  • Familiarity with CMS Medicare regulations.
  • Experience supporting NCQA accreditation activities.
  • Experience preparing regulatory responses, audits, or quality improvement initiatives.
Why Join Western Health Advantage?
At WHA, you'll have the opportunity to make a meaningful impact on the quality and accessibility of healthcare for our members. You'll collaborate with experienced clinical leaders in a supportive, mission-driven environment that values clinical excellence, regulatory compliance, and continuous improvement.

Apply