D-SNP Utilization Management RN

Central Coast Salary Range - $84,877 - $123,072

While candidates from anywhere in California are welcome to apply, there is a strong preference for those who reside on the Central Coast (Ventura, Santa Barbara, San Luis Obispo, Monterey, and Santa Cruz Counties). This role may offer opportunities for remote work; however, familiarity with and proximity to our local customers is valued.

Job Summary

The Utilization Management (UM) RN for the D-SNP program plays a critical role in ensuring members receive timely, medically necessary, and cost-effective care. This position is responsible for:
 

• Conduct Clinical Reviews and Authorization Determinations:
   

  • Perform clinical reviews, prior authorization decisions, and concurrent reviews for inpatient and outpatient services using evidence-based criteria and regulatory guidelines for dual-eligible members.
     

• Coordinate Care and Support Member Outcomes:
   

  • Collaborate with care managers, providers, and interdisciplinary teams to ensure timely, medically necessary, and cost-effective care, helping to reduce barriers and improve health outcomes for D-SNP members.
     

• Ensure Regulatory Compliance and Quality Standards:
   

  • Apply appropriate regulatory guidelines and maintain compliance with both Medicare and Medi-Cal requirements in all utilization management activities.
     

• Support Education and Continuous Improvement:
   

  • Contribute to process improvement initiatives, compliance efforts, and the development of educational materials for providers and members.

Duties and Responsibilities
 

• Conduct Clinical Reviews and Authorization Determinations:
   

  • Review and evaluate requests for inpatient, outpatient, and ancillary services for D-SNP members, ensuring medical necessity, cost-effectiveness, and alignment with the D-SNP Model of Care using evidence-based criteria such as MCG guidelines, Medi-Cal criteria, and CenCal Health policies.
     

  • Perform timely and accurate utilization management reviews, including:
     

    • Prospective (pre-service) prior authorization.
       

    • Concurrent reviews in acute, subacute, skilled nursing, and long-term care settings.
       

    • Retrospective (post-service) reviews.
       

    • Selective claims reviews and other case types as indicated.
       

  • Compose accurate and timely draft notices of action, non-coverage, and other regulatory notifications in accordance with Medicare Advantage and Medi-Cal requirements.
     

  • Maintain comprehensive documentation in care management systems, including case review summaries and proper citation of clinical sources.
     

  • Manage denials and appeals, coordinating with providers, members, and compliance teams to ensure proper resolution.
     

• Coordinate Care and Support Member Outcomes:
   

  • Collaborate daily with physicians, interdisciplinary care teams, and other providers to assess treatment plans and address complex medical, functional, cognitive, and psychosocial needs of D-SNP members.
     

  • Apply utilization review principles and evidence-based guidelines to promote care continuity across settings, including skilled nursing and long-term care.
     

  • Participate in interdisciplinary team rounds, care transition planning, and post-discharge coordination to reduce avoidable hospitalizations and support member well-being.
     

  • Coordinate with Pharmacy, Quality Improvement, Health Programs, and other internal departments to ensure integrated care and appropriate use of resources.
     

• Ensure Regulatory Compliance and Quality Standards:
   

  • Serve as a liaison to providers and internal teams, promoting understanding of utilization management processes, operational standards, and D-SNP-specific requirements.
     

  • Identify and escalate potential quality of care concerns, collaborating with Medical Management leadership and quality teams.
     

  • Support data collection, audits, and reporting to meet CMS, DHCS, and internal compliance standards.
     

  • Uphold member confidentiality and adhere to HIPAA and other relevant laws and regulations.
     

  • Stay informed about current federal, state, and D-SNP program guidelines related to utilization management.
     

• Support Education and Continuous Improvement: 
   

  • Educate providers and internal staff on coverage determinations, appeals processes, and alternative treatment options in alignment with D-SNP requirements.
     

  • Assist in the development, implementation, and evaluation of quality improvement initiatives and departmental projects aimed at improving D-SNP performance and member outcomes.
     

  • Contribute to internal process improvement and workflow optimization within the utilization management program.
     

Knowledge / Skills / Abilities
 

• Comprehensive Clinical Knowledge: Strong understanding of adult health conditions, chronic disease management, and complex care needs common among D-SNP populations, including functional, cognitive, and psychosocial aspects.
   

• Utilization Management Expertise: Skilled in applying utilization review principles across prospective, concurrent, and retrospective reviews. Proficient with nationally recognized criteria such as MCG guidelines, Medi-Cal, Medicare Advantage regulations, and CenCal Health policies.
   

• Regulatory and Compliance Awareness: In-depth knowledge of Medicare Advantage, Medi-Cal, CMS, DHCS, and other federal/state guidelines governing D-SNP utilization management and documentation standards.
   

• Clinical Decision-Making and Judgment: Ability to accurately assess medical necessity, appropriateness, and cost-effectiveness of inpatient, outpatient, and ancillary services, ensuring alignment with the D-SNP Model of Care.
   

• Strong Communication and Collaboration: Excellent verbal and written communication skills to liaise effectively with physicians, interdisciplinary care teams, providers, members, and internal stakeholders. Capable of educating providers on coverage determinations and appeals.
   

• Documentation and Reporting Skills: Proficient in documenting clinical findings, case reviews, and regulatory notifications in care management systems, ensuring accuracy and timeliness.
   

• Quality Improvement and Problem-Solving: Ability to identify quality of care concerns, participate in interdisciplinary rounds and care transitions, and contribute to quality improvement initiatives that enhance member outcomes.
   

• Appeals and Denials Management: Skilled in managing denials and appeals processes, coordinating with providers, members, and compliance teams for resolution. Work collaboratively with member services.
   

• Analytical and Data Management Skills: Competent in supporting data collection, audits, and reporting to meet regulatory and internal requirements. Detail-oriented in reviewing medical records and utilization data.
   

• Teamwork and Interdepartmental Coordination: Ability to work collaboratively with Pharmacy, Quality Improvement, Health Programs, and other internal teams to promote integrated, member-centered care.
   

• Time Management and Prioritization: Efficiently manages multiple cases and priorities to meet deadlines and operational standards in a dynamic healthcare environment.
   

• Technological Proficiency: Experience with electronic medical records (EMR), utilization management software, and reporting tools.
   

• Ethical and Legal Integrity: Commitment to maintaining member confidentiality and compliance with HIPAA and all applicable laws and regulations.
  
   

Education and Experience
 

Required:
 

• Current, active, unrestricted California Registered Nurse (RN) and/or Nurse Practitioner (NP) License with a minimum of two (2) years of experience in this nursing role in a managed care setting, hospital, health plan or other equivalent setting.
   

• Minimum of 3 years of clinical nursing experience, preferably in acute care, case management, utilization management, or a related healthcare setting.
   

• Experience working with adult and complex chronic populations, including those in skilled nursing, long-term care, or post-acute settings.
   

• Prior experience with utilization management processes such as prior authorization, concurrent and retrospective reviews, and appeals management strongly preferred.
   

• Familiarity with Medicare Advantage and Medicaid (Medi-Cal).
   

• Demonstrated knowledge of clinical guidelines and evidence-based criteria (e.g., MCG guidelines) for utilization review.
   

Preferred:
 

• Bachelor of Science in Nursing (BSN).
   

• Certification in case management, utilization, quality, or healthcare management, such as CCM, CMCN, CPHQ, HCQM, CPUM, CPUR, ACM or board certification in an area of specialty.