Claire Myers Consulting
Location:
Santa Barbara, CA (Remote Eligible)
Classification:
Exempt
Compensation:
$95,000–$138,000 annually, depending on experience
Overview Our client is seeking an experienced Registered Nurse to join their Dual Special Needs Program (D‑SNP) team. This position ensures members receive timely, medically necessary, and cost‑effective care through clinical review, care coordination, and collaboration with internal and external partners. The ideal candidate has a strong clinical background, experience with utilization management, and a commitment to improving outcomes for dual‑eligible members.
Responsibilities
Conduct clinical reviews and prior authorization determinations for inpatient, outpatient, and ancillary services using evidence‑based criteria.
Complete concurrent and retrospective reviews to ensure medical necessity and regulatory compliance.
Coordinate with physicians, interdisciplinary teams, and providers to support integrated, member‑centered care.
Participate in care transition planning and interdisciplinary rounds to improve continuity of care and reduce avoidable hospitalizations.
Manage denials, appeals, and regulatory notifications while maintaining thorough documentation in the care‑management system.
Apply Medicare and Medi‑Cal guidelines, ensuring adherence to federal, state, and internal compliance standards.
Support education efforts for providers and staff on coverage determinations and process improvements.
Qualifications
Current, active, unrestricted California RN or NP license required.
Minimum 3 years of clinical nursing experience (acute care, case management, or utilization management preferred).
At least 2 years of experience in a managed care or health‑plan setting.
Working knowledge of Medicare Advantage, Medi‑Cal, and evidence‑based criteria (e.g., MCG).
Excellent communication, documentation, and problem‑solving skills.
Strong attention to detail, time management, and ability to prioritize in a fast‑paced environment.
Proficiency with EMR and utilization‑management systems.
Preferred
Bachelor of Science in Nursing (BSN).
Certification in case management, utilization, or quality management (CCM, CPHQ, CPUR, etc.).
This position can be remote, with occasional in‑person meetings. Regular business hours apply, with potential for limited on‑call participation.
Job Details
Seniority level:
Associate
Employment type:
Full‑time
Job function:
Health Care Provider
Industries:
Medical Practices
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Santa Barbara, CA (Remote Eligible)
Classification:
Exempt
Compensation:
$95,000–$138,000 annually, depending on experience
Overview Our client is seeking an experienced Registered Nurse to join their Dual Special Needs Program (D‑SNP) team. This position ensures members receive timely, medically necessary, and cost‑effective care through clinical review, care coordination, and collaboration with internal and external partners. The ideal candidate has a strong clinical background, experience with utilization management, and a commitment to improving outcomes for dual‑eligible members.
Responsibilities
Conduct clinical reviews and prior authorization determinations for inpatient, outpatient, and ancillary services using evidence‑based criteria.
Complete concurrent and retrospective reviews to ensure medical necessity and regulatory compliance.
Coordinate with physicians, interdisciplinary teams, and providers to support integrated, member‑centered care.
Participate in care transition planning and interdisciplinary rounds to improve continuity of care and reduce avoidable hospitalizations.
Manage denials, appeals, and regulatory notifications while maintaining thorough documentation in the care‑management system.
Apply Medicare and Medi‑Cal guidelines, ensuring adherence to federal, state, and internal compliance standards.
Support education efforts for providers and staff on coverage determinations and process improvements.
Qualifications
Current, active, unrestricted California RN or NP license required.
Minimum 3 years of clinical nursing experience (acute care, case management, or utilization management preferred).
At least 2 years of experience in a managed care or health‑plan setting.
Working knowledge of Medicare Advantage, Medi‑Cal, and evidence‑based criteria (e.g., MCG).
Excellent communication, documentation, and problem‑solving skills.
Strong attention to detail, time management, and ability to prioritize in a fast‑paced environment.
Proficiency with EMR and utilization‑management systems.
Preferred
Bachelor of Science in Nursing (BSN).
Certification in case management, utilization, or quality management (CCM, CPHQ, CPUR, etc.).
This position can be remote, with occasional in‑person meetings. Regular business hours apply, with potential for limited on‑call participation.
Job Details
Seniority level:
Associate
Employment type:
Full‑time
Job function:
Health Care Provider
Industries:
Medical Practices
#J-18808-Ljbffr