Utilization Management Clinical Reviewer
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Job Description
Utilization Management Clinical Reviewer managing high-acuity inpatient cases for Evernorth Health Services. Assessing medical necessity, coordinating safe transitions, and advocating for California members.
Responsibilities:
- Manage and coordinate an assigned caseload of complex, high-acuity, or account-sensitive inpatient cases
- Complete prospective, concurrent, and retrospective clinical reviews for acute inpatient care, rehabilitation, referrals, select outpatient services, and durable medical equipment, as applicable
- Apply approved clinical guidelines and tools to evaluate medical necessity, level of care, covered services, treatment goals, risk factors, and discharge needs
- Review the daily census, prioritize cases, request relevant clinical information, and document decisions, interventions, and outcomes accurately and on time
- Create member-centered short- and long-term care plans with measurable goals, follow-up timeframes, and criteria for transition or closure
- Coordinate with members, families, physicians, facilities, vendors, caregivers, and internal partners to support timely discharge or transfer
- Identify and help resolve gaps in care, barriers to discharge, readmission risk, and service delays
- Educate members about benefits, care options, costs, and community resources
- Serve as a member advocate and liaison within benefit, regulatory, contractual, and program requirements
- Escalate complex cases, quality-of-care concerns, and service delays to managers, medical directors, or Quality partners
- Identify referrals for complex or specialty case management programs and coordinate transitions
- Build relationships with internal teams, providers, customers, and community resources
- Support customer or auditor visits, special projects, peer consultation, and related duties
Requirements:
- Must currently reside in California
- Active, unencumbered California RN licensure
- Minimum of two years of direct clinical RN experience in an inpatient or managed care setting
- Bachelor’s degree in nursing or a related field (preferred)
- Ability to assess complex clinical information, identify barriers, recommend solutions, and make sound decisions
- Strong written and verbal communication, organization, time management, research, analytical, negotiation, and problem-solving skills
- Ability to work independently, manage competing priorities, and collaborate in a fast-paced, matrixed environment
- Proficiency using computers and clinical or case management systems
- Experience in medical management, utilization management, or case management within a health plan or hospital setting
- Knowledge of managed care products, care management strategies, and community, state, and federal resources
- Demonstrated ability to anticipate needs, coordinate services, and build cooperative relationships with diverse internal and external partners
- Must be able to work an 8-hour shift between 8:00 a.m. and 5:00 p.m. PST, Monday-Friday
- Home internet connection must use cable broadband or fiber optic service with at least 10 Mbps download and 5 Mbps upload
Benefits:
- Annual bonus plan eligibility
- Medical, vision, and dental benefits starting on day one
- Well-being and behavioral health programs starting on day one
- 401(k)
- Company-paid life insurance
- Tuition reimbursement
- Minimum of 18 days of paid time off per year
- Paid holidays
- Leaves of absence
- Remote work arrangement
- Cable broadband or fiber optic internet service requirement for home working
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