Utilization Management RN (Medicare) – Remote California

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Candidates must be authorized to work in the U.S. without sponsorship

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Third-party/C2C arrangements are not available for this role

* _______________________________________________________________________________________________________ Remote California RN opportunity supporting Medicare utilization review activities. Seeking a licensed Registered Nurse (RN) with Utilization Management, inpatient care, and Medicare review experience for a 6+ month remote contract role paying $55/hr. If you are a California-based RN with Utilization Management and Medicare experience seeking a fully remote opportunity, we encourage you to apply today for immediate consideration. Candidates must have a minimum of 5 years of direct patient care experience in a hospital inpatient setting, along with strong clinical assessment, communication, and critical thinking skills. _______________________________________________________________________________________________________

Overview

Our client, a provider of Health, Dental, Vision, Medicaid and Medicare Healthcare service plans in the state of California with 4.7 million members and $22.9 billion of annual revenues, seeks an experienced Utilization Management RN (Medicare) – Remote California Position: Utilization Management RN (Medicare) – Remote California Location: Remote within California, including Los Angeles, San Diego, Sacramento, San Jose, Oakland, Fresno, Irvine, the Bay Area, Northern California, and Southern California regions. Duration: 6+ Month Contract (Potential Extension) Schedule: Monday–Friday | 8:00 AM – 5:00 PM PST Hours: 40 hours/week Pay Rate: $55/hr W2 Candidates must have a secure HIPAA-compliant workspace and reliable high-speed internet connection to support remote utilization review activities. Position Summary We are seeking an experienced Utilization Management Nurse to support Medicare utilization review activities in a remote capacity. This role is responsible for performing prospective, concurrent, and retrospective utilization reviews using evidence-based clinical criteria and regulatory guidelines to ensure appropriate, quality, and cost-effective care for members.

Key Responsibilities

• Perform prospective, concurrent, and retrospective utilization reviews for Medicare members using BSC and CMS evidence-based guidelines, policies, and nationally recognized clinical criteria.
• Ensure appropriate discharge planning based on member acuity and level of care needs.
• Coordinate durable medical equipment (DME) and post-service needs to support quality and cost-effective discharge planning.
• Prepare and present cases to the Medical Director for medical necessity determinations and oversight.
• Communicate determinations to providers and members in compliance with state, federal, and accreditation requirements.
• Develop and maintain member-centered documentation and correspondence that meets regulatory and accreditation standards.
• Identify potential quality of care concerns, service delays, or treatment delays and intervene appropriately.
• Refer members to Case Management when acute inpatient needs impact discharge planning.
• Participate in staff meetings, clinical rounds, and weekly huddles.
• Maintain productivity and quality metrics for assigned casework.
• Ensure a HIPAA-compliant remote work environment.

Required Qualifications

• Associate’s Degree in Nursing required; Bachelor’s Degree preferred.
• Minimum 2 years of Utilization Management experience.
• Minimum 5 years of direct patient care experience in a hospital inpatient setting.
• Strong clinical assessment, communication, and critical thinking skills.

Preferred Qualifications

• ER and/or ICU experience.
• Experience using MCG guidelines.
• Experience managing Medicare cases.

Recruiter Contact Info Sajag Bhardwaj Email: [email protected] www.ameritconsulting.com I'd love to talk to you if you think this position is right up your alley, and assure prompt communication, whichever direction. If you're looking for rewarding employment and a company that puts its employees first, we'd like to work with you. Company Overview: Amerit Consulting is a nationwide staffing and consulting firm supporting Fortune 500 clients across healthcare, technology, engineering, and professional services. With over 2,000 employees across 47 states, Amerit specializes in contract, temporary, and direct hire staffing solutions. Amerit Consulting provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws. This policy applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation and training. Applicants, with criminal histories, are considered in a manner that is consistent with local, state and federal laws.