ZipRecruiter

Log In

1

Utilization Management Rep Jobs in California (NOW HIRING)

LSMA Management Inc

Denial Coordinator

San Bernardino, CA · On-site

$26 - $29/hr

Preferred: 1+ years of Utilization Management experience. Any combination of educational and work ... are representative of those required to successfully perform the essential functions of this job.

LSMA Management Inc

Denial Coordinator

San Bernardino, CA · On-site

$26 - $29/hr

Preferred: 1+ years of Utilization Management experience. Any combination of educational and work ... are representative of those required to successfully perform the essential functions of this job.

Highmark Health

Senior Pharmacist - Strategy

Sacramento, CA

$63.50 - $76.25/hr

... utilization management policies. Manage formulary administration and oversight, ensuring all aspects of work adhere to applicable state and federal requirements. May represent Highmark in applicable ...

next page

Showing results 1-20

All JobsUtilization Management Rep JobsUtilization Management Rep Jobs in California

Utilization Management Rep information

What are the key skills and qualifications needed to thrive as a Utilization Management Representative, and why are they important?

To thrive as a Utilization Management Representative, you need a solid understanding of healthcare policies, medical terminology, and insurance processes, typically supported by a background in healthcare administration or a related field. Familiarity with utilization review software, electronic medical records (EMR), and claims management systems is typically required. Strong attention to detail, effective communication, and customer service skills help you excel when coordinating between providers, members, and insurance teams. These competencies ensure accurate case review, regulatory compliance, and positive patient outcomes in a complex healthcare environment.

How does a Utilization Management Rep collaborate with healthcare providers and internal teams to ensure appropriate patient care?

A Utilization Management Rep frequently interacts with healthcare providers, such as physicians and nurses, to gather clinical information and clarify treatment plans. They also work closely with internal medical directors, case managers, and claims teams to review authorization requests and determine medical necessity based on established guidelines. Effective communication and teamwork are key, as the role requires balancing patient needs, provider requests, and payer policies to facilitate timely, appropriate care decisions. This collaboration ensures that patients receive necessary services while helping to control healthcare costs.

What is the difference between Utilization Management Rep vs Utilization Review Coordinator?

AspectUtilization Management RepUtilization Review Coordinator
CertificationsCPUR, RHIT, or similarCPUR, RHIT, or similar
Work EnvironmentHealthcare insurance companies, hospitalsHealthcare insurance companies, hospitals
Job FocusReviewing and authorizing healthcare servicesCoordinating and managing review processes

Both roles involve reviewing healthcare services, often requiring similar certifications. The Utilization Management Rep primarily assesses and authorizes services, while the Utilization Review Coordinator manages the review process and coordinates between providers and payers. They often work in similar environments within the healthcare insurance industry, with overlapping responsibilities but different focus areas.

What is a Utilization Management Rep?

A Utilization Management Representative, often called a UM Rep, is a professional who reviews medical service requests to ensure that treatments and procedures are medically necessary and covered by a patient's insurance plan. They work with healthcare providers, insurance companies, and patients to review clinical information, authorize care, and sometimes suggest alternative treatments based on policy guidelines. UM Reps play a key role in managing healthcare costs while maintaining quality care by adhering to established criteria and regulations.
What are popular job titles related to Utilization Management Rep jobs in California? For Utilization Management Rep jobs in California, the most frequently searched job titles are:
What job categories do people searching Utilization Management Rep jobs in California look for? The top searched job categories for Utilization Management Rep jobs in California are:
Utilization Management Rep jobs near you

On-Call Registered Nurse

LSMA Management Inc

San Bernardino, CA • On-site

$45 - $48/hr

Full-time

Posted 5 days ago

Job description

Job Type
Full-time
Description
JOB SUMMARY
The On-Call Registered Nurse (RN) is a California-licensed registered nurse responsible for providing after-hours medical management coverage when the Medical Management office is closed. The role supports utilization management (UM), care coordination, discharge processing, and urgent authorization activities, ensuring continuity of care, appropriate utilization of services, and compliance with applicable federal, state, accreditation, and health plan requirements within a healthcare MSO environment.
Requirements
MINIMUM & PREFERRED QUALIFICATIONS:
Education/Training
Minimum: Graduated from an accredited Registered Nursing program.
Preferred: Bachelor of Science in Nursing (BSN)
Experience
Minimum: One year of clinical experience as a Registered Nurse.
Preferred: One to two years of experience in utilization management, case management, discharge planning, MSO/IPA, or health plan settings.
Any combination of educational and work experience that would be equivalent to the stated minimum requirements would qualify for consideration of this position.
Certification(s)
Current state Registered Nursing license.
Skills, Knowledge & Abilities
• Knowledge of utilization management principles, medical necessity determination, and regulatory requirements relevant to managed care.
• Familiarity with Milliman Care Guidelines, CMS requirements, NCQA standards, and delegated UM workflows.
• Basic understanding of ICD-10, CPT, and HCPCS coding.
• Strong clinical judgment, critical thinking, and problem-solving skills within RN scope of practice.
• Effective verbal and written communication skills, including professional interaction with physicians and clinical leadership.
• Ability to independently prioritize and manage multiple urgent tasks during on-call hours.
• Proficiency with electronic medical records, utilization management platforms, and Microsoft Office applications.
PHYSICAL, MENTAL & ENVIRONMENTAL REQUIREMENTS:
The physical, mental, and environmental demands described below are representative of those required to perform the essential functions of this position, with or without reasonable accommodation. The role involves primarily sedentary work with extended periods of sitting, screen time, typing, and telephone use, along with occasional standing, walking, bending, and lifting of materials up to 20 pounds. The position requires sustained mental focus to evaluate complex clinical information and make timely, sound decisions during on-call hours, as well as the ability to work evenings, nights, weekends, and holidays in accordance with assigned on-call schedules.
PAY RANGE
$45.00 - $48.00 / hourly
Salary Description
$45.00 - $48.00 / hourly

Apply