Utilization Review Nurse

We are recruiting for a Utilization Review Nurse to join a large healthcare organization within the Sacramento region. The Utilization Review Nurse is responsible for overseeing the daily operations of the UM Pre-Authorization team, ensuring referral requests are processed consistently, accurately, and within regulatory time frames. This position plays a key role in workflow oversight, staff support, regulatory compliance, and collaboration with internal and external partners.

The ideal candidate will have 7+ years of UM experience with charge, lead, supervisory, or management responsibilities and experience working with health plan auditors.

• Pay range: $54-$66/hour DOE
• Hybrid
• License
  
  Required:
  
  Registered Nurse – CA
• 6-month contract role

• Oversee day‑to‑day operations of the Pre‑Authorization team, ensuring timely response and appropriate evaluation of referral reviews.
• Ensure correct selection and application of clinical criteria and accurate preparation of cases for UM Physician Reviewers when indicated.
• Ensure timely verbal and written documentation and completion of referral files.
• Maintain adequate staffing levels, assign work appropriately, and adjust workflow to meet departmental goals.
• Organize, structure, and chair at least one pre‑authorization meeting per month, involving additional staff as appropriate.
• Motivate and coach staff, including new‑hire training, problem‑solving support, and participation in special projects.
• Assist the Manager with performance activities, including monitoring, coaching, education, and providing feedback to team members.
• Develop a Pre‑Authorization team that is consistent, knowledgeable, accurate, and committed to meeting timelines.
• Ensure UM Physicians receive all relevant information needed for accurate referral review.
• Foster strong working relationships between the Pre‑Authorization team, the Medical Director, and Physician Reviewers.
• Promote appropriate application of clinical criteria, policies, and guidelines to prior‑authorization referrals.
• Participate in audit preparation and serve as a resource during health plan audits.
• Monitor, compile, analyze, and report UM data, trends, and performance metrics.

• Graduate of an accredited school of nursing.
• Registered Nurse (CA) license required.
• Bachelor’s degree in Nursing or equivalent experience required.
• 5+ years of clinical nursing experience required.
• 3+ years of utilization management experience in a health plan, UM operations, acute care, or subacute utilization review required.
• Demonstrated leadership and management skills.
• Knowledge of applicable federal/state regulations and accreditation standards.
• Working knowledge of UM review processes and regulatory requirements.
• Ability to monitor, compile, analyze, and report data/statistics.
• Excellent interpersonal, written, and verbal communication skills.
• Demonstrated ability to lead, mentor, and develop staff.
• Ability to work effectively with all levels of the organization and external partners.
• Proficiency with Microsoft Office (Word, Excel) and other clinical/administrative systems.