Job Description

A rapidly expanding healthcare management organization is seeking an experienced RN or LVN with strong background in utilization management, authorizations, and hospital denial reviews. This role supports insurance-side clinical operations and requires deep familiarity with California insurance regulations, utilization management standards, and HMO/Medicare Advantage processes. The ideal candidate has 3-5 years of experience in UM or case management, understands authorization workflows, and is comfortable overseeing departmental processes. Candidates based in Fresno, CA are preferred; however, remote applicants with strong knowledge of California insurance regulations who can work PST hours will also be considered.
Responsibilities:

• Review, prepare, and process prior authorizations, concurrent reviews, and clinical documentation requests in alignment with California insurance regulations.
• Evaluate and write up hospital denial reviews, appeals, and reconsiderations with strong clinical justification.
• Oversee daily workflows and support operational efficiency within the utilization management team.
• Ensure all UM activities comply with state laws, payer requirements, and organizational policies.
• Collaborate with hospitals, providers, case managers, and internal teams to ensure timely and accurate determinations.
• Maintain thorough documentation of clinical decisions, rationale, and regulatory compliance.
• Serve as a resource for UM policies, California regulatory updates, and utilization management standards.
• Participate in departmental quality improvement efforts and process optimization.
• Communicate professionally with providers, health plans, and internal stakeholders regarding authorizations and determinations.
• Other duties as assigned.

Requirements:

• Active RN or LVN license in the state of California.
• 3-5 years of experience in utilization management, authorizations, case management, or hospital review.
• Strong experience writing and evaluating authorizations, denials, and appeals.
• Thorough understanding of California insurance laws, HMO requirements, and Medicare/Medicare Advantage guidelines.
• Ability to oversee departmental workflows and support UM staff.
• Excellent written communication, clinical documentation, and review skills.
• Strong knowledge of medical terminology, clinical guidelines, and payer criteria.
• Proficiency with EMR/UM software platforms and Microsoft Office tools.
• Preferred: Fresno-based; remote applicants with CA insurance expertise and PST availability welcome.

LVN: 70K-80K ; RN: 100K-150K.

Skills Required