Use your expertise, compassion, and kindness to transform the patient experience. When you join UCLA Health as a nurse, you’ll deliver leading-edge care as you build an exceptional career with a health system that’s consistently ranked among the best in the country.
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.
- 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.
EMPLOYMENT SCAM ALERT:
UCLA Health Recruitment is currently being targeted by scam artists through external job board sites. Review some tips in order to avoid becoming targeted. El reclutamiento de salud de UCLA actualmente está siendo atacado por estafadores a través de sitios de juntas de trabajo externos. Revisar algunos consejos para evitar ser apuntado.
“The environment is nurturing and fosters growth. When I come to work, I know what I'm doing matters.”
VINCENT, Sr. CLS Specialist, Toxicology
MONICA
I've been blessed to touch so many lives through my serving. It's a privilege to uplift other employees with words of encouragement and a smile.
SOZIT
The first thing i noticed when i joined the team was how everyone is very welcoming and friendly with supportive management. I did not feel like an outsider.
EDGAR
Once I joined, I knew UCLA Health was THE place to be due to the growth potential and training offered
RENE
If you want to grow professionally, this is the right place for you.
ERA
We are family here. We support each other. We collect together.
ELIZABETH
It’s so diverse and inclusive here. There’s always the opportunity to share your thoughts. It's a place where you feel you belong.
JERRY
Your career path at UCLA Health will enable you to follow a myriad of avenues and turns. It opens up a wide variety of opportunities.
ORLANDO
There’s a togetherness and higher level of commitment to teamwork at UCLA Health. We are several groups and teams that work together with a common goal which is to improve our patients experience.
DAVID
UCLA Health walks the walk and talks the talk! It's an incredible feeling to work for an organization that always puts the patient first. I am honored to work in full alignment with the UCLA Health Mission and Vision.
DR. ISLA GARRAWAY
UCLA has incredible resources and a team science approach. The ability to work with collaborative teams and access the amazing resources around campus is the best part about being at UCLA.
RADU
UCLA is very diverse in its personnel as well as its many research fields studied
JENNA
UCLA Health provides so many opportunities to exchange ideas, share moments and grow. I have learned a lot about team management and relationship building.
SHARON
I was looking for a job to further my career and continue to improve and learn as a therapist.
TARO
I have been blessed to be surrounded by supportive colleagues who aspire me to be the best version of myself.
Awards & recognition
