Travel Nurse RN - Manager, Utilization Review
Costa Mesa, California
Hoag Memorial Hospital - 2995 Red Hill Ave

Job Opportunity: UM Nurse Manager

Location: Costa Mesa, California
Employment Type: Direct Hire

Job Summary

• Lead and ensure the team is properly trained to conduct medical necessity reviews on Pre-Service/Prior-Authorization, Retrospective, and Post Claims reviews for Urgent/Expedited and Routine/Standard referrals/authorization requests.
• Ensure compliance with Federal, State, Health Plan, and Accreditation (URAC, NCQA) requirements.
• Oversee staff accountability through evaluations, reporting, and performance observations.
• Ensure timely and accurate documentation in the Medical Management System.
• Collaborate with hospital staff, providers, Medical Director, and care teams to meet members’ health needs.
• Maintain continuity of care for inpatients through early discharge planning and coordination with case managers.
• Monitor and report inappropriate referrals/authorizations.
• Manage network provider steerage and negotiate out-of-network requests.
• Identify and manage high-risk members with complex medical and psychosocial needs.
• Coordinate post-discharge care to ensure timely outpatient follow-up and treatment plans.
• Serve as a subject matter expert on clinical criteria and coverage determinations (NCD, LCA, LCD, MCG, NCCN, etc.).
• Contribute to program goals for cost containment and quality medical delivery.
• Apply process improvement principles and participate in UM Committee meetings and health plan audits.

Contract Length

• 10 weeks

Required Qualifications

• Registered Nurse (RN) licensed in California.
• Minimum 5 to 10 years of nursing experience in a Medical Group, Hospital, Health Plan, or Risk-Based MSO setting.
• Minimum 3 to 5 years of nursing management experience in a Medical Group, Hospital, Health Plan, or Risk-Based MSO setting.
• Proficient with MS Word, Excel, and MS Office programs.
• Experience with Medicare/Medicare Advantage Plans, Commercial Plans, HMO, and/or Medi-Cal/ACA standards.
• Strong problem-solving, critical thinking, and decision-making skills.
• Collaborative and team-oriented approach to decision-making.

Preferred Qualifications

• 2 to 3 years of UM Manager experience in a Medical Group, Hospital, Health Plan, or Risk-Based MSO setting.
• Bachelor’s degree in a healthcare-related field.

Certifications & Licensure

• No additional certifications or licensure required beyond RN license.

Prior Travel Experience

• Not required or specified.