Utilization Management Clinical

The Utilization Manager, Registered Nurse, is an office-based nursing position responsible for supporting high-quality patient care through clinical oversight, utilization management, and real-time guidance to field clinicians. This role serves as a key clinical resource within the organization, assisting with nursing calls, care coordination, and clinical decision-making to promote positive patient outcomes while ensuring regulatory and payer compliance.

Key responsibilities include:

• Provide clinical support and guidance to field clinicians, including RNs, LVNs, and therapy staff.

• Take and triage nursing calls from clinicians, patients, and caregivers as appropriate.

• Collaborate with field staff to assist with clinical problem-solving, patient status changes, and care planning.

• Review plans of care and clinical documentation to ensure appropriate utilization of services and skilled need.

• Monitor visit frequencies and service utilization in alignment with physician orders, payer guidelines, and agency standards.

• Support case managers with recertifications, discharges, transitions of care, and care coordination.

• Participate in interdisciplinary collaboration to promote continuity of care and effective communication.

• Identify clinical risks or concerns and escalate issues appropriately.

• Support compliance with Medicare Conditions of Participation, regulatory requirements, and agency policies.

• Contribute to quality improvement initiatives focused on patient outcomes, documentation accuracy, and clinical best practices.

Required Qualifications

• Active Registered Nurse (RN) license in the state of California.

• Strong clinical assessment, critical-thinking, and decision-making skills.

• Excellent verbal and written communication skills.

• Ability to work collaboratively with interdisciplinary teams.

• Proficiency with electronic medical records (EMR) systems and basic computer applications.

Preferred Qualifications

• Experience in utilization management, case management, or clinical coordination.

• Home Health experience preferred but not required.

• Knowledge of Medicare home health regulations, payer guidelines, and Conditions of Participation.

• Experience providing clinical support, education, or mentorship to field clinicians.

• Strong organizational skills with the ability to manage multiple priorities in a fast-paced office environment.