UCLA Health and David Geffen School of Medicine
UM Prior Authorization Review Nurse - RN
UCLA Health and David Geffen School of Medicine, Los Angeles, California, United States, 90079
Job ID: 23831
Description
At UCLA Health, the Utilization Management (UM) Review Nurse plays a vital role in ensuring the delivery of high-quality, evidence-based care. This position is responsible for reviewing and evaluating clinical documentation related to prior authorization requests for medical services. The UM Review Nurse applies clinical judgment, regulatory standards, and established guidelines to determine medical necessity and benefit eligibility. This role works collaboratively with medical directors, physicians, and interdisciplinary teams to support appropriate care coordination and efficient utilization of resources. Key Responsibilities: Conducts clinical reviews of prior authorization requests to evaluate medical necessity and benefit coverage. Applies UCLA Health protocols and national clinical guidelines (e.g., InterQual, Milliman) in review decisions. Coordinates escalations to medical directors and ensures timely documentation of determinations. Communicates with providers to obtain clarification and support the decision-making process. Ensures compliance with CMS, state, federal, and UCLA Health standards. Reviews and validates cases submitted by non-clinical staff. Audits documentation to ensure compliance and accuracy. Provides mentorship and feedback to coordinators to enhance workflow efficiency. Collaborates with UCLA Health medical directors and interdisciplinary teams for case resolution. Serves as a liaison between clinicians, internal departments, and members. Documents all review findings and decisions in the case management system and supports reporting initiatives. Educates providers and staff on UM policies, criteria, and review processes. Identifies process improvement opportunities and contributes to performance improvement projects. Remains current with clinical best practices and UM regulatory changes.
Salary Range: $61.79 - $79.91 Hourly
Qualifications
BSN and/or MSN required Current California RN license required Demonstrates resourcefulness, effective written and oral communication, diplomacy, organizational, and analytical skills required Proficient knowledge in evidence-based medical necessity criteria, health plan medical necessity criteria and CMS criteria required A minimum of three years of experience in utilization management, preferred Team leading or management experience, preferred Self-directed, assertive and creative in problem solving, systems planning and patient care management in a high-volume work environment Strong critical thinking and the ability to apply knowledge Ability to work effectively and collaboratively with interdisciplinary teams Proficient computer skills including Internet search capabilities, Microsoft Word, Excel, and Managed Care software (i.e. EZ Cap, Diamond, IDX) required Ability to effectively communicate to physician/staff the medical necessity/appropriateness/level of care criteria that is necessary for acute care hospitalization. Ability to effectively communicate to the payer the medical necessity/appropriateness/level of care criteria that is necessary for acute care hospitalization. Skill in setting priorities that accurately reflect the relative importance of job responsibilities. Skill in abstracting and interpreting medical information from patient records. Working knowledge of laws, rules, and regulations regarding utilization review and discharge planning functions of government programs such Medicare, Medi-Cal, and CCS. Clinical experience sufficient to understand and communicate medical diagnosis and courses of treatment to professional and non-professional personnel. A PASSION FOR ADVANCING NURSING EXCELLENCE At UCLA Health and the David Geffen School of Nursing, you’ll be inspired and empowered to reach your fullest potential in your nursing career. Through close collaboration with other outstanding clinicians in our inclusive and engaging working environment, you can play a critical role in the delivery of our world-class care. Our Center for Nursing Excellence, state-of-the-art technology, shared governance, recognition programs, and more, will equip you to go further in your nursing practice than you thought possible. It’s no wonder we’ve achieved Magnet® status multiple times in multiple locations. If you’re ready to live out your passion and advance your nursing career, we invite you to explore opportunities throughout our award-winning system, including: ?
Ronald Reagan UCLA Medical Center ?
UCLA Medical Center, Santa Monica ?
Resnick Neuropsychiatric Hospital at UCLA ?
UCLA Mattel Children’s Hospital ?
More than 280 community-based clinics throughout Southern California No matter where you serve with UCLA Health, the cultural, recreational, and lifestyle advantages of our Southern California locations will elevate your standard of living.
Description
At UCLA Health, the Utilization Management (UM) Review Nurse plays a vital role in ensuring the delivery of high-quality, evidence-based care. This position is responsible for reviewing and evaluating clinical documentation related to prior authorization requests for medical services. The UM Review Nurse applies clinical judgment, regulatory standards, and established guidelines to determine medical necessity and benefit eligibility. This role works collaboratively with medical directors, physicians, and interdisciplinary teams to support appropriate care coordination and efficient utilization of resources. Key Responsibilities: Conducts clinical reviews of prior authorization requests to evaluate medical necessity and benefit coverage. Applies UCLA Health protocols and national clinical guidelines (e.g., InterQual, Milliman) in review decisions. Coordinates escalations to medical directors and ensures timely documentation of determinations. Communicates with providers to obtain clarification and support the decision-making process. Ensures compliance with CMS, state, federal, and UCLA Health standards. Reviews and validates cases submitted by non-clinical staff. Audits documentation to ensure compliance and accuracy. Provides mentorship and feedback to coordinators to enhance workflow efficiency. Collaborates with UCLA Health medical directors and interdisciplinary teams for case resolution. Serves as a liaison between clinicians, internal departments, and members. Documents all review findings and decisions in the case management system and supports reporting initiatives. Educates providers and staff on UM policies, criteria, and review processes. Identifies process improvement opportunities and contributes to performance improvement projects. Remains current with clinical best practices and UM regulatory changes.
Salary Range: $61.79 - $79.91 Hourly
Qualifications
BSN and/or MSN required Current California RN license required Demonstrates resourcefulness, effective written and oral communication, diplomacy, organizational, and analytical skills required Proficient knowledge in evidence-based medical necessity criteria, health plan medical necessity criteria and CMS criteria required A minimum of three years of experience in utilization management, preferred Team leading or management experience, preferred Self-directed, assertive and creative in problem solving, systems planning and patient care management in a high-volume work environment Strong critical thinking and the ability to apply knowledge Ability to work effectively and collaboratively with interdisciplinary teams Proficient computer skills including Internet search capabilities, Microsoft Word, Excel, and Managed Care software (i.e. EZ Cap, Diamond, IDX) required Ability to effectively communicate to physician/staff the medical necessity/appropriateness/level of care criteria that is necessary for acute care hospitalization. Ability to effectively communicate to the payer the medical necessity/appropriateness/level of care criteria that is necessary for acute care hospitalization. Skill in setting priorities that accurately reflect the relative importance of job responsibilities. Skill in abstracting and interpreting medical information from patient records. Working knowledge of laws, rules, and regulations regarding utilization review and discharge planning functions of government programs such Medicare, Medi-Cal, and CCS. Clinical experience sufficient to understand and communicate medical diagnosis and courses of treatment to professional and non-professional personnel. A PASSION FOR ADVANCING NURSING EXCELLENCE At UCLA Health and the David Geffen School of Nursing, you’ll be inspired and empowered to reach your fullest potential in your nursing career. Through close collaboration with other outstanding clinicians in our inclusive and engaging working environment, you can play a critical role in the delivery of our world-class care. Our Center for Nursing Excellence, state-of-the-art technology, shared governance, recognition programs, and more, will equip you to go further in your nursing practice than you thought possible. It’s no wonder we’ve achieved Magnet® status multiple times in multiple locations. If you’re ready to live out your passion and advance your nursing career, we invite you to explore opportunities throughout our award-winning system, including: ?
Ronald Reagan UCLA Medical Center ?
UCLA Medical Center, Santa Monica ?
Resnick Neuropsychiatric Hospital at UCLA ?
UCLA Mattel Children’s Hospital ?
More than 280 community-based clinics throughout Southern California No matter where you serve with UCLA Health, the cultural, recreational, and lifestyle advantages of our Southern California locations will elevate your standard of living.