UM Prior Authorization Review Nurse - RN

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  JOB DUTIES
  

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.

Key Responsibilities:

• Conducts clinical reviews of prior authorization requests to evaluate medical necessity and benefit coverage.
• Applies UCLA Health protocols and national clinical guidelines (e.g., InterQual, Milliman) in review decisions.
• Coordinates escalations to medical directors and ensures timely documentation of determinations.
• Communicates with providers to obtain clarification and support the decision-making process.
• Ensures compliance with CMS, state, federal, and UCLA Health standards.
• Reviews and validates cases submitted by non-clinical staff.
• Audits documentation to ensure compliance and accuracy.
• Provides mentorship and feedback to coordinators to enhance workflow efficiency.
• Collaborates with UCLA Health medical directors and interdisciplinary teams for case resolution.
• Serves as a liaison between clinicians, internal departments, and members.
• Documents all review findings and decisions in the case management system and supports reporting initiatives.
• Educates providers and staff on UM policies, criteria, and review processes.
• Identifies process improvement opportunities and contributes to performance improvement projects.
• Remains current with clinical best practices and UM regulatory changes.

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  JOB 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, preferred
• Team 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 teams
• Proficient 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 programs such Medicare, Medi-Cal, and CCS.
• Clinical experience sufficient to understand and communicate medical diagnosis and courses of treatment to professional and non-professional personnel.