✓You’ll need

Licensure

✓Active, unrestricted Registered Nurse license in California.

Certifications

Certification in Case Management (CCM), Certified Professional Utilization preferred

Review (CPUR), Certified Professional Coder (CPC), or a related specialty. preferred

AAPC certification, such as Certified Professional Coder, Certified preferred

Education

✓Bachelor’s degree in Nursing or a related healthcare field, or an equivalent

Master’s degree in Healthcare Administration, Public Health, Business preferred

Qualifications

✓combination of healthcare education and experience.

✓Five or more years of professional healthcare experience in a clinical

✓quality improvement, utilization management, or related setting.

✓Three or more years of experience in utilization management, case management

✓and/or clinical auditing.

✓Thorough knowledge of utilization management criteria, including InterQual

✓and MCG guidelines.

✓Thorough knowledge of payer requirements, medical necessity determinations

✓and denial management processes.

✓Advanced knowledge of quality improvement standards, clinical chart review

✓abstraction methodologies, and regulatory requirements.

✓Ability to use data collection, aggregation, validation, analysis, and

✓reporting techniques to support utilization management and quality improvement

✓activities.

✓Strong analytical and critical thinking skills with the ability to interpret

✓complex clinical, operational, and financial information.

✓Strong written and verbal communication skills for preparing reports

✓summaries, recommendations, and appeal documentation.

Administration, or a related field. preferred

Professional Biller, or Revenue Cycle Management Specialist preferred

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About the role

Description Patient Business Services Provide clinical review, audit, analytical, and quality improvement support for utilization management, medical necessity determinations, and denial prevention and response efforts across the health system. As the Utilization Management Nurse Auditor, you will conduct concurrent and retrospective case reviews, support denial appeals, analyze utilization and denial trends, and collaborate with Care Coordination, Clinical Documentation Integrity, Revenue Cycle, and Physician Advisor teams. This role helps strengthen level-of-care determinations, clinical documentation, payer compliance, and operational and financial performance. In this role, you will:
Review concurrent and retrospective clinical denials to assess admission status, level of care, length of stay, medical necessity, and other factors contributing to denials.
Prepare clinical summaries and supporting documentation for first- and second-level appeals, support payer, RAC, and Medi-Cal audit responses, and collaborate with Revenue Cycle and Physician Advisor teams to strengthen appeal strategies.
Analyze denial and audit findings to identify trends, root causes, documentation gaps, avoidable delays, and opportunities to improve utilization management performance.
Evaluate cases using established utilization review criteria, including InterQual, MCG, organizational guidelines, and payer requirements, and escalate complex or questionable cases as appropriate.
Partner with Physician Advisors, Care Coordination teams, and clinical staff to improve documentation supporting medical necessity, status designation, and accurate level-of-care determinations.
Prepare reports, dashboards, presentations, case summaries, trend analyses, and recommendations for leadership and Utilization Management Committee review.
Support performance improvement initiatives focused on length of stay, avoidable days, denial rates, status accuracy, utilization outcomes, and data integrity.
Serve as a clinical resource while collaborating with clinical and operational leaders across the health system to support utilization management, clinical quality, patient safety, care progression, discharge planning, and continuous improvement efforts. Salary Range: $98,200 to $214,600 annually Qualifications Required
Bachelor’s degree in Nursing or a related healthcare field, or an equivalent combination of healthcare education and experience.
Five or more years of professional healthcare experience in a clinical, quality improvement, utilization management, or related setting.
Three or more years of experience in utilization management, case management, and/or clinical auditing.
Active, unrestricted Registered Nurse license in California.
Thorough knowledge of utilization management criteria, including InterQual and MCG guidelines.
Thorough knowledge of payer requirements, medical necessity determinations, and denial management processes.
Advanced knowledge of quality improvement standards, clinical chart review, abstraction methodologies, and regulatory requirements.
Ability to use data collection, aggregation, validation, analysis, and reporting techniques to support utilization management and quality improvement activities.
Strong analytical and critical thinking skills with the ability to interpret complex clinical, operational, and financial information.
Strong written and verbal communication skills for preparing reports, summaries, recommendations, and appeal documentation.
Ability to collaborate effectively with physicians, clinical staff, operational leaders, and external regulatory representatives.
Proficiency with electronic health records and healthcare data management applications, including familiarity with systems such as Epic.
Project management and organizational skills with the ability to manage multiple priorities and deadlines. Preferred
Master’s degree in Healthcare Administration, Public Health, Business Administration, or a related field.
Certification in Case Management (CCM), Certified Professional Utilization Review (CPUR), Certified Professional Coder (CPC), or a related specialty.
AAPC certification, such as Certified Professional Coder, Certified Professional Biller, or Revenue Cycle Management Specialist

Utilization Management Nurse Auditor

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About the role