UM Prior Authorization Review Nurse – RN

Job 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.

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, preferredTeam 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 teamsProficient 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 progr…

About the Hospital

UCLA Health hospitals ranked #1 in both Los Angeles and California and rose to #3 nationally in an annual evaluation published today by U.S. News & World Report - the highest set of rankings UCLA has received in its history.

UCLA Health once again earned a coveted spot on the national honor roll, which names only the 20 hospitals that provide the highest-quality care across a wide range of procedures and conditions.