Utilization Management Nurse

Job Description

• Responsible for written and verbal communication with contract providers and internal staff to promote timely coordination of care and dissemination of policies and procedures.
• Collaborates with the Member Service Department and the Provider Relations Department regarding quality of care and other grievance issues to facilitate timely problem resolutions.
• Utilizes clinical guidelines as well as Medi‑Cal criteria to review DME, home care, and outpatient service requests for medical necessity and benefit coverage while processing referral requests.
• Identifies and refers cases for quality of care, coordination of benefits, and third‑party liability issues as appropriate.
• Maintains knowledge of covered benefits for all programs.
• Identifies and refers cases appropriate for various internal programs. Shares information as necessary with appropriate Population Health Management teams:
  Case Management, Transitions of Care, Major Organ Transplant and Community Support Services including but not limited to Enhanced Care Management.
• Identifies authorization issues and brings those requiring attention to the UM Outpatient Clinical Supervisor.
• Reviews requests for non‑par services and coordinates these with input from the Medical Director based on par provider availability in the member's geographic area.
• Selects, formats, proofreads and prints appropriate member and provider denial letters prior to mailing.
• Determines medical appropriateness and necessity of care using established criteria within mandated turnaround times.
• Appropriately refers cases that do not meet medical necessity to the Medical Director.
• Keeps current with California Children’s Services benefits and guidelines for coordination of services.
• Other duties as determined based on Department needs.

• Registered Nurse (RN) with an active, current, unrestricted CA license.
• Minimum of two years (2) full‑time clinical experience in acute care, community health setting, public health nursing or chronic disease management.
• Bachelor’s Degree from an accredited school or equivalent in Nursing, Health Administration or related healthcare field preferred.
• Understanding of utilization management principles preferred.
• Experience with MCG Health LLC clinical guidelines and Medi‑CAL coverage preferred.
• Experience working in case management or care coordination is a plus.
• Knowledge of Kern County Community resources for seniors and people with disabilities is a plus.

• Valid California Driver License and proof of State‑required auto liability. Up to 10% driving.
• Bilingual (English/Spanish) preferred.

Experience Level: Intermediate Level

Job Type &

Location:

Contract to Hire position based out of Bakersfield, CA. This is a fully onsite position.

Pay range: $51.00 – $51.00 per hour.

• Medical, dental & vision
• Critical Illness, Accident, and Hospital
• 401(k) Retirement Plan – Pre‑tax and Roth post‑tax contributions available
• Life Insurance (Voluntary Life & AD&D for the employee and dependents)
• Short and long‑term disability
• Health Spending Account (HSA)
• Transportation benefits
• Employee Assistance Program
• Time Off/Leave (PTO, Vacation or Sick Leave)

This position is anticipated to close on March 7, 2026.

We’re partners in transformation. We help clients activate ideas and solutions to take advantage of a new world of opportunity. We are a team of 80,000 strong, working with over 6,000 clients, including 80% of the Fortune 500, across North America, Europe and Asia. As an industry leader in Full‑Stack Technology Services, Talent Services, and real‑world application, we work with progressive leaders to drive change.

That’s the power of true partnership. TEKsystems is an Allegis Group company.

The company is an equal‑opportunity employer and will consider all applications without regard to race, sex, age, color, religion, national origin, veteran status, disability, sexual orientation, gender identity, genetic information or any characteristic protected by law.