About the Company
Kaiser Permanente is one of America’s leading integrated health care organizations. Founded in 1945, it is a non-profit organization headquartered in Oakland, California, with medical centers and offices across eight states and the District of Columbia. We are dedicated to providing high-quality, affordable health care services and improving the health of our members and the communities we serve. Our mission is to provide total health for mind, body, and spirit.
Job Description
We are seeking a dedicated and experienced Utilization Review Nurse with a strong administrative focus to join our remote team. This 100% remote position plays a critical role in ensuring appropriate resource utilization, quality of care, and compliance with regulatory guidelines. The Utilization Review Nurse will be responsible for reviewing medical records, applying evidence-based criteria, and communicating with healthcare providers to facilitate optimal patient outcomes while managing the administrative aspects of the review process. This role requires excellent clinical judgment, strong organizational skills, and the ability to work independently in a virtual environment.
Key Responsibilities
- Conduct thorough and timely medical necessity reviews for various healthcare services (inpatient, outpatient, ancillary services) using established criteria and guidelines.
- Communicate professionally and effectively with providers, members, and interdisciplinary team members regarding review determinations and alternative care options.
- Document all review activities, decisions, and communications accurately and comprehensively in the electronic health record system.
- Identify potential quality of care concerns or under/over-utilization patterns and escalate as appropriate.
- Maintain up-to-date knowledge of clinical guidelines, regulatory requirements (e.g., CMS, state regulations), and health plan policies.
- Participate in interdepartmental meetings and collaborate with case management, discharge planning, and claims departments.
- Assist in the development and implementation of utilization management policies and procedures.
- Provide education and support to healthcare providers regarding utilization review processes and criteria.
Required Skills
- Current active and unrestricted Registered Nurse (RN) license in California.
- Minimum of 3 years of clinical nursing experience.
- Minimum of 1 year of experience in Utilization Review, Case Management, or Quality Management.
- Strong understanding of medical terminology, diagnostic procedures, and treatment modalities.
- Proficiency in applying evidence-based clinical criteria (e.g., InterQual, Milliman Care Guidelines).
- Excellent written and verbal communication skills.
- Strong analytical, critical thinking, and problem-solving abilities.
- Proficient computer skills, including experience with electronic health records (EHR) and Microsoft Office Suite.
- Ability to work independently and manage time effectively in a remote work environment.
Preferred Qualifications
- Bachelor of Science in Nursing (BSN) or Master of Science in Nursing (MSN).
- Certification in Case Management (CCM) or Certification in Utilization Review (CUR).
- Experience with Kaiser Permanente's internal systems and processes.
- Demonstrated experience in a large integrated healthcare system or health plan setting.
- Familiarity with HEDIS, Stars, and other quality metrics.
Perks & Benefits
- Comprehensive medical, dental, and vision coverage.
- Paid time off, including holidays and vacation.
- 401(k) retirement plan with company match.
- Life insurance and disability benefits.
- Tuition reimbursement and professional development opportunities.
- Employee assistance program.
- Wellness programs and resources.
- Opportunity to work from home 100% remotely.
How to Apply
If you are interested in this position, please click the "Apply Now" button below. To ensure your application is properly considered, please prepare the following:
- An up-to-date Resume or CV
- A brief cover letter summarizing your experience and motivation
Applications are reviewed on a rolling basis. Only shortlisted candidates will be contacted for an interview.
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