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Utilization Review Director Jobs in California (NOW HIRING)

KPC Global MSO

Utilization Review LVN

Santa Ana, CA · On-site

Job Title: Utilization Review LVN SUMMARY The purpose of the Utilization Management LVN is to ... Identification of referrals to the medical director for review * Appropriate letter language and ...

New

Prime Healthcare

Utilization Review Nurse LVN

Ontario, CA · On-site

$71K - $99K/yr

Assists Director of UR Dept. in providing oversight and monitoring productivity of UR Coordinators ... Utilization Management experience required. * Excellent interpersonal relationship skills with ...

Kheir Clinic

Utilization Specialist

Los Angeles, CA · On-site

$64K - $75K/yr

The Utilization Specialist will work closely with the clinical teams, Director of Patient Services ... Review scheduling reports and data analytics to assess current patient flow and identify potential ...

Kheir-Clinic-

Utilization Specialist

Lancaster, CA · On-site

$65 - $75/hr

The Utilization Specialist will work closely with the clinical teams, Director of Patient Services ... Review scheduling reports and data analytics to assess current patient flow and identify potential ...

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All JobsUtilization Review JobsUtilization Review Director JobsUtilization Review Director Jobs in California

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How much do utilization review director jobs pay per hour?

As of Sep 6, 2026, the average hourly pay for utilization review director in California is $41.73, according to ZipRecruiter salary data. Most workers in this role earn between $32.98 and $47.93 per hour, depending on experience, location, and employer.

What does a utilization review director do?

A Utilization Review Director oversees the evaluation of medical necessity, appropriateness, and efficiency of healthcare services provided to patients. They lead teams that review patient care requests, manage compliance with regulations, and implement strategies to ensure cost-effective care without compromising quality. Their responsibilities often include policy development, data analysis, and collaboration with healthcare providers to optimize resource use and improve patient outcomes.

What are the key skills and qualifications needed to thrive as a utilization review director, and why are they important?

To thrive as a Utilization Review Director, you need a deep understanding of clinical guidelines, healthcare regulations, and case management principles, typically supported by a nursing or related healthcare degree and relevant licensure. Familiarity with utilization management software, electronic health records (EHR), and certifications such as Certified Case Manager (CCM) or Accredited Case Manager (ACM) is common in the field. Strong leadership, communication, analytical thinking, and decision-making skills help you effectively manage teams and ensure compliance. These competencies ensure efficient resource use, regulatory adherence, and high-quality patient outcomes within healthcare organizations.

What are some common challenges faced by a utilization review director, and how can they be addressed?

A Utilization Review Director often navigates challenges such as balancing regulatory compliance with organizational goals, managing interdisciplinary teams, and keeping up with evolving healthcare policies. Staying proactive with ongoing education, fostering open communication among staff, and implementing efficient review processes can help address these issues. Additionally, leveraging data analytics and technology streamlines case reviews and ensures evidence-based decision-making, ultimately improving both patient outcomes and operational efficiency.

What is the difference between Utilization Review Director vs Utilization Review Nurse?

AspectUtilization Review DirectorUtilization Review Nurse
CredentialsRN license, management experience, certifications (e.g., CCM)RN license, certification in case management or utilization review (e.g., CUC)
Work EnvironmentAdministrative, leadership roles overseeing teamsClinical, review of patient cases, direct patient care
Employer & IndustryHospitals, insurance companies, healthcare organizationsHospitals, insurance companies, healthcare providers
Search & Comparison IntentLeadership, management, strategic planning in utilization reviewClinical review, case assessment, patient care coordination

The Utilization Review Director typically oversees review teams and manages utilization strategies, requiring leadership skills and management experience. In contrast, the Utilization Review Nurse focuses on clinical case assessments and patient care reviews. Both roles require RN licensure and relevant certifications but differ mainly in scope and responsibilities.

What are the most commonly searched types of Utilization Review jobs in California?

The most popular types of Utilization Review jobs in California are:

What cities in California are hiring for Utilization Review Director jobs?

Cities in California with the most Utilization Review Director job openings:

Utilization Review Director jobs near you

Utilization Review LVN

KPC Global MSO

Santa Ana, CA • On-site

Other

Medical

Posted 3 days ago

New

Job description

Job Title: Utilization Review LVN
SUMMARY
The purpose of the Utilization Management LVN is to ensure quality of patient care, effective utilization of available health services, review of admissions for medical necessity and necessity of continued stay in the inpatient setting. Ensures members have a safe discharge plan in place prior to discharge from the inpatient setting.
RESPONSIBILITIES AND DUTIES:

  • Responsible for providing timely and accurate referral determination
  • Identification of referrals to the medical director for review
  • Appropriate letter language and coding (denials, deferrals, modifications)
  • Appropriate selection of the preferred and contracted providers
  • Proper identification of eligibility and health plan benefits
  • Proper coding to trigger the record to be routed to a different work queue or to trigger the proper determination notice to be sent out
  • Responsible for working closely with supervisor/lead to address issues and delays that can cause a failure to meet or maintain compliance.
  • Meets or exceeds production and quality metrics.
  • Work directly with the provider(s) and health plan Medical Director to facilitate quality service to the member and provider.
  • Identifies Clinical Program opportunities and refers members to the appropriate healthcare program (e.g. case management, engagement team, and disease management)..
  • Maintains and keeps in total confidence, all files, documents and records that pertain to the business operations.
  • All other job related duties as assigned
EDUCATION & EXPERIENCE REQUIREMENTS:
  • CA LVN license required.
  • Minimum 3 years' of acute care experience preferred.
  • Minimum two (2) years managed care experience in UM/CM Department, preferred
SKILLS & ABILITIES REQUIREMENTS:
  • Knowledge of CMS, State Regulations, URAC and NCQA guidelines preferred.
  • ICD-9 and CPT coding experience a plus
  • Experienced computer skills with Microsoft Word, Microsoft Outlook, Excel and experience working in a health plan medical management documentation system a plus
  • Experience in EZ-CAP preferred
  • Medical Terminology preferred
PHYSICAL REQUIREMENTS:
  • Body Positions: Sitting and standing for prolonged periods.
  • Body Movements: Arm and hand dexterity.
  • Body Senses: Must have command of close and distant sight, color perception and hearing.
  • Strength: Ability to lift and move up to 25-pounds.
Working Environment:
  • Work in an office, where the climate is controlled.
  • OSHA exposure category: I
  1. Category I - Position includes tasks that involve exposure to Blood borne Pathogens.
  2. Category II - Position includes tasks that do not have exposure to Bloodborne Pathogens, however employment may require unplanned Category I tasks.
  3. Category III - Positions includes tasks that do not involve exposure to Bloodborne Pathogens. This position would not be required to perform Category I tasks.

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