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Utilization Case Manager Jobs in California (NOW HIRING)

Acadia Healthcare

Case Manager

San Marcos, CA · On-site

$29 - $38/hr

Previous experience in case management and/or utilization review preferred. Licenses/Certifications ... AOD Registration is required. * AOD Certification is preferred. * Registration/Certification must ...

Acadia Healthcare

Case Manager

San Marcos, CA · On-site

$29 - $38/hr

Previous experience in case management and/or utilization review preferred. Licenses/Certifications ... AOD Registration is required. * AOD Certification is preferred. * Registration/Certification must ...

Acadia Healthcare

Case Manager

San Diego, CA · On-site

$29.14 - $38/hr

Previous experience in case management and/or utilization review preferred. Licenses/Certifications ... AOD Registration is required. * AOD Certification is preferred. * Registration/Certification must ...

Acadia Healthcare

Case Manager

San Diego, CA · On-site

$29.14 - $38/hr

Previous experience in case management and/or utilization review preferred. Licenses/Certifications ... AOD Registration is required. * AOD Certification is preferred. * Registration/Certification must ...

Loma Linda University Health

Case Manager

Loma Linda, CA · On-site

$20.50 - $26.50/hr

Maintains a solid working knowledge of specialized case and utilization management methodologies and practices and applies concepts to everyday practice. Ensures medical appropriateness criteria ...

Loma Linda University Health

Case Manager

Loma Linda, CA

$20.50 - $26.50/hr

Maintains a solid working knowledge of specialized case and utilization management methodologies and practices and applies concepts to everyday practice. Ensures medical appropriateness criteria ...

Loma Linda University Health

Case Manager

Loma Linda, CA · On-site

$20.50 - $26.50/hr

Maintains a solid working knowledge of specialized case and utilization management methodologies and practices and applies concepts to everyday practice. Ensures medical appropriateness criteria ...

Loma Linda University Health

Case Manager

Loma Linda, CA · On-site

$59.18 - $79.60/hr

Maintains a solid working knowledge of specialized case and utilization management methodologies and practices and applies concepts to everyday practice. Ensures medical appropriateness criteria ...

Loma Linda University Health

Case Manager

Loma Linda, CA · On-site

$20.50 - $26.50/hr

Maintains a solid working knowledge of specialized case and utilization management methodologies and practices and applies concepts to everyday practice. Ensures medical appropriateness criteria ...

Loma Linda University Health

Case Manager

Loma Linda, CA · On-site

$59.18 - $79.60/hr

Maintains a solid working knowledge of specialized case and utilization management methodologies and practices and applies concepts to everyday practice. Ensures medical appropriateness criteria ...

Loma Linda University Health

Case Manager

Loma Linda, CA · On-site

$20.50 - $26.50/hr

Maintains a solid working knowledge of specialized case and utilization management methodologies and practices and applies concepts to everyday practice. Ensures medical appropriateness criteria ...

Loma Linda University Health

Case Manager

Loma Linda, CA · On-site

$20.50 - $26.50/hr

Maintains a solid working knowledge of specialized case and utilization management methodologies and practices and applies concepts to everyday practice. Ensures medical appropriateness criteria ...

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All JobsUtilization Case JobsUtilization Case Manager JobsUtilization Case Manager Jobs in California

Utilization Case Manager information

What is a utilization case manager?

A Utilization Case Manager is a healthcare professional responsible for evaluating the necessity, appropriateness, and efficiency of medical services provided to patients. They review patient cases, coordinate with healthcare providers, and ensure that treatments are in line with established guidelines and insurance requirements. Their goal is to optimize patient outcomes while managing costs and ensuring compliance with regulations. Utilization Case Managers often work in hospitals, insurance companies, or managed care organizations.

How does a utilization case manager typically collaborate with healthcare providers and insurance companies?

Utilization Case Managers play a key role in coordinating care between healthcare providers and insurance companies. They review patient cases to ensure that the recommended treatments are medically necessary and align with insurance policies. This often involves regular communication with doctors, nurses, and insurance representatives to gather information, clarify treatment plans, and advocate for appropriate patient care. Strong collaboration skills are essential, as Utilization Case Managers must balance the needs of patients with organizational guidelines while maintaining positive professional relationships.

What degree do I need for utilization review?

Utilization case managers typically need at least a bachelor's degree in healthcare, nursing, social work, or a related field. Some positions may require a master's degree or professional certification, such as a Certified Case Manager (CCM) or Certified Professional in Healthcare Quality (CPHQ), to advance in the role or handle complex cases.

What are the key skills and qualifications needed to thrive as a utilization case manager?

To thrive as a Utilization Case Manager, you need a background in nursing or social work, strong analytical skills, and a solid understanding of healthcare regulations and insurance processes, often supported by RN licensure or certification in case management (e.g., CCM). Familiarity with utilization management software, electronic health records (EHRs), and payer authorization systems is essential. Excellent communication, critical thinking, and negotiation skills help facilitate collaboration among patients, providers, and payers. These skills ensure appropriate care delivery, cost management, and compliance with healthcare standards.

What is the difference between Utilization Case Manager vs Utilization Review Nurse?

AspectUtilization Case ManagerUtilization Review Nurse
CredentialsRN license, case management certificationRN license, certification in utilization review
Work EnvironmentCase management teams, hospitals, insurance companiesUtilization review departments, hospitals, insurance providers
Primary FocusCoordinating patient care, discharge planning, resource allocationAssessing medical necessity, reviewing patient records for appropriateness
Common UsageBroader case management roles, patient advocacySpecific review of medical necessity and insurance claims

While both roles require RN licensure and focus on patient care, the Utilization Case Manager primarily coordinates overall patient services and discharge planning, whereas the Utilization Review Nurse concentrates on evaluating the medical necessity of treatments for insurance purposes. Understanding these distinctions helps in choosing the right career path or job search focus.

What are popular job titles related to Utilization Case Manager jobs in California? For Utilization Case Manager jobs in California, the most frequently searched job titles are:
What job categories do people searching Utilization Case Manager jobs in California look for? The top searched job categories for Utilization Case Manager jobs in California are:
What cities in California are hiring for Utilization Case Manager jobs? Cities in California with the most Utilization Case Manager job openings:
Utilization Case Manager jobs near you
Infographic showing various Utilization Case Manager job openings in California as of August 2026, with employment types broken down into 82% Full Time, and 18% Contract. Highlights an 82% In-person, and 18% Remote job distribution.

Appeals & Grievances Nurse

Western Health Advantage

Sacramento, CA • On-site

Full-time

Re-posted 12 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 BringRequired 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.

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