Impresiv Health
Description:
Impresiv Health is seeking a Utilization Management Registered Nurse to support one of our California-based health plan clients during a critical operational stabilization period. This role focuses on pre-service and concurrent reviews for medical services, with a strong emphasis on high-risk and complex members.
The ideal candidate is self-directed, confident in UM protocols, and brings experience working in managed care environments. You will collaborate with multidisciplinary teams, apply clinical criteria to authorization reviews, and contribute to efforts that improve turnaround times, reduce risk, and ensure compliance with DMHC, NCQA, and CMS standards.
What You Will Do: Perform timely and accurate utilization management reviews for pre-service and concurrent requests using MCG or InterQual criteria Approve services that meet eligibility, benefit coverage, and medical necessity standards Escalate complex or non-certifiable cases to the Medical Director for physician-level review Communicate UM review outcomes verbally and in writing to providers and internal stakeholders Participate in daily huddles and status updates with leadership and clinical operations teams Serve as a liaison between the health plan and external providers to support timely, member-centered care Manage reviews for high-acuity or complex cases, supporting efforts to reduce avoidable admissions Identify and report quality of care concerns and patterns Maintain compliance with federal, state, and accrediting body requirements (DMHC, CMS, NCQA) Support initiatives to improve operational efficiency, timeliness, and compliance metrics Document case reviews clearly and consistently in accordance with regulatory and plan requirements Conduct face-to-face assessments or selective claims reviews when needed What You Will Bring:
Active, unrestricted California Registered Nurse (RN) license Minimum of 3 years of nursing experience in an acute, post-acute, or outpatient setting Minimum of 2 years of Utilization Management experience within a managed care or payor setting Experience managing Medicare Advantage members Previous experience working with D-SNP Proficiency with MCG or InterQual clinical review guidelines Ability to work independently and manage complex case reviews with minimal oversight Strong communication and documentation skills Experience writing clinical denial letters is preferred Certification in Case Management, Utilization Review, or Quality (e.g., CCM, CMCN, CPHQ) preferred Experience supporting health plans through operational turnaround, backlog reduction, or audit readiness preferred Familiarity with DMEPOS, behavioral health, or pediatric populations preferred About Impresiv Health: Impresiv Health is a healthcare consulting partner specializing in clinical & operations management, enterprise project management, professional services, and software consulting services. We help our clients increase operational efficiency by delivering innovative solutions to solve their most complex business challenges.
Our approach is and has always been simple. First, think and act like the customers who need us, and most importantly, deliver what larger organizations cannot do - provide tangible results that add immediate About Impresiv Health value, at a rate that cannot be beaten. Your success matters, and we know it.
That's Impresiv!
The ideal candidate is self-directed, confident in UM protocols, and brings experience working in managed care environments. You will collaborate with multidisciplinary teams, apply clinical criteria to authorization reviews, and contribute to efforts that improve turnaround times, reduce risk, and ensure compliance with DMHC, NCQA, and CMS standards.
What You Will Do: Perform timely and accurate utilization management reviews for pre-service and concurrent requests using MCG or InterQual criteria Approve services that meet eligibility, benefit coverage, and medical necessity standards Escalate complex or non-certifiable cases to the Medical Director for physician-level review Communicate UM review outcomes verbally and in writing to providers and internal stakeholders Participate in daily huddles and status updates with leadership and clinical operations teams Serve as a liaison between the health plan and external providers to support timely, member-centered care Manage reviews for high-acuity or complex cases, supporting efforts to reduce avoidable admissions Identify and report quality of care concerns and patterns Maintain compliance with federal, state, and accrediting body requirements (DMHC, CMS, NCQA) Support initiatives to improve operational efficiency, timeliness, and compliance metrics Document case reviews clearly and consistently in accordance with regulatory and plan requirements Conduct face-to-face assessments or selective claims reviews when needed What You Will Bring:
Active, unrestricted California Registered Nurse (RN) license Minimum of 3 years of nursing experience in an acute, post-acute, or outpatient setting Minimum of 2 years of Utilization Management experience within a managed care or payor setting Experience managing Medicare Advantage members Previous experience working with D-SNP Proficiency with MCG or InterQual clinical review guidelines Ability to work independently and manage complex case reviews with minimal oversight Strong communication and documentation skills Experience writing clinical denial letters is preferred Certification in Case Management, Utilization Review, or Quality (e.g., CCM, CMCN, CPHQ) preferred Experience supporting health plans through operational turnaround, backlog reduction, or audit readiness preferred Familiarity with DMEPOS, behavioral health, or pediatric populations preferred About Impresiv Health: Impresiv Health is a healthcare consulting partner specializing in clinical & operations management, enterprise project management, professional services, and software consulting services. We help our clients increase operational efficiency by delivering innovative solutions to solve their most complex business challenges.
Our approach is and has always been simple. First, think and act like the customers who need us, and most importantly, deliver what larger organizations cannot do - provide tangible results that add immediate About Impresiv Health value, at a rate that cannot be beaten. Your success matters, and we know it.
That's Impresiv!