Travel Nurse RN - Manager, Utilization ReviewHoag Memorial Hospital - 2995 Red Hill Ave • Costa Mesa, CA, US

[error_messages.no_longer_accepting]

Travel Nurse RN - Manager, Utilization Review

Hoag Memorial Hospital - 2995 Red Hill Ave • Costa Mesa, CA, US

[job_card.30_days_ago]

[job_preview.job_type]

[job_card.full_time]

[job_card.job_description]

Job Description

Certification Details

Registered Nurse (RN) - California State License

Job Details

Ensures that the team are properly trained to conduct medical necessity reviews on incoming Pre-Service/Prior-Authorization, Retrospective and Post Claims reviews on Urgent/Expedited and Routine/Standard referrals/authorizations requests in compliance with any Federal, State, Health Plan, Accreditation (URAC, NCQA) requirements.
Assures staff accountability through routine evaluation, reporting and performance observation, and through timely, thorough preparation of annual review.
Ensures that staff achieves performance goals while adhering to applicable internal and external policies, procedures, rules and guidelines.
Ensures that the UM team documents on the Medical Management System in a timely manner, all supporting clinical information, outreach attempts (if applicable) and criteria used to make a determination.
Adheres to compliance with all federal, state, health plan and accreditation by all laws, standards and regulations.
Collaborate with hospital/facility staff, providers, coordinators, Medical Director, members and their care givers to provide the level of care necessary to meet member’s health needs.
Maintain an active role in ensuring the continuity of care for all inpatients through early discharge planning and working with hospital discharge planners/ case managers or other staff in the early identification discharge needs/disposition and determining appropriate level of care placement.
Monitor, track, and report any trending inappropriate referrals/authorization to the UM Medical Director and/or the Director of Medical Management.
Ensure network provider steerage and happening on OON network request and negotiate with Clinic Operations as appropriate.
Identify and manage high risk members for readmission or with complex medical and psychosocial needs.
Collaborate with Case Management Team to coordinate post discharge care and services to ensure timely outpatient follow-up, and the provider treatment plan, medications & outpatient services are in place prior to discharge.
Serves as a subject matter expert on appropriate use, interpretation and documentation of clinical criteria in the review process such as National Coverage Determination (NCD), Local Coverage Articles (LCA), Local Coverage Determination (LCD), California Coverage Determinations, Health Plan Medical Coverage Policies, MCG, NCCN etc.
Contribute to program goals and objectives in containing health care costs and maintaining a high-quality medical delivery system through the program procedures for conducting UM activities.
Demonstrate proficiency with the principles and methodologies of process improvement.
Strategically apply these in the execution of responsibilities in support of a process focused approach.
Participate on UM Committee meetings and annual health plan audit.
Other duties as assigned.

Job Requirements

Registered Nurse (RN) in the State of California.
At least 5 to 10 years of Nursing Experience in a Medical Group, Hospital, Health Plan or Risk-Based MSO setting.
At least 3 to 5 years of Nursing Management Experience in a Medical Group, Hospital, Health Plan or Risk-Based MSO setting.
Computer experience in MS Word, Excel and MS Office Programs.
Experience with Medicare/Medicare Advantage Plans, Commercial Plans, HMO, and/or Medi-Cal/ACA standards.
Proven and effective problem-solving, critical thinking, and decision-making skills.
Collaborative, team-oriented approach to decision-making.

Additional Details

Preferred Skills & Experience: 2 to 3 years of UM Manager Experience in a Medical Group, Hospital, Health Plan or Risk-Based MSO setting.
Required Education: Bachelor's degree in a health care-related field.

[job_alerts.create_a_job]

Travel Nurse RN - Manager, Utilization Review • Costa Mesa, CA, US

[internal_linking.similar_jobs]

Travel Nurse - RN - ICU - Intensive Care Unit

Medical Solutions • Westminster, CA, US

[job_card.full_time]

Medical Solutions is seeking an experienced Intensive Care Unit Registered Nurse for an exciting Travel Nursing job in Westminster, CA.Shift: 2x12 hr days Start Date: 04/06/2026 Duration: 13 weeks....[show_more]

[last_updated.last_updated_variable_days] • [promoted]

Travel Nurse - RN - ICU - Intensive Care Unit - $1940 / Week

LRS Healthcare - Nursing • Santa Ana, CA, US

[job_card.full_time]

LRS Healthcare - Nursing is seeking an experienced Intensive Care Unit Registered Nurse for an exciting Travel Nursing job in Los Angeles, CA.Shift: Inquire Start Date: 03/30/2026 Duration: 13 week...[show_more]

[last_updated.last_updated_variable_days] • [promoted]

Travel Nurse - RN - Case Manager - $2329.1 / Week

Atlas MedStaff • Lakewood, CA, US

[job_card.full_time]

Atlas MedStaff is seeking an experienced Case Manager Registered Nurse for an exciting Travel Nursing job in Lakewood, CA.Shift: 5x8 hr days Start Date: 03/23/2026 Duration: 13 weeks Pay: $2329.Atl...[show_more]

[last_updated.last_updated_variable_days] • [promoted]

Travel Nurse - RN - ICU - Intensive Care Unit - $2918.8 / Week

InSync Consulting Services • Santa Ana, CA, US

[job_card.full_time]

InSync Consulting Services is seeking an experienced Intensive Care Unit Registered Nurse for an exciting Travel Nursing job in Los Angeles, CA.Shift: 4x12 hr nights Start Date: 03/30/2026 Duration...[show_more]

[last_updated.last_updated_variable_days] • [promoted]

Travel Nurse - RN - ICU - Intensive Care Unit - $2163.72 / Week

InSync Consulting Services • Santa Ana, CA, US

[job_card.full_time]

InSync Consulting Services is seeking an experienced Intensive Care Unit Registered Nurse for an exciting Travel Nursing job in Los Angeles, CA.Shift: 3x12 hr nights Start Date: 03/30/2026 Duration...[show_more]

[last_updated.last_updated_variable_days] • [promoted]

Travel Nurse - RN - ICU - Intensive Care Unit - $2154.4 / Week - Hiring Now

TRS Healthcare • Santa Ana, CA, US

[job_card.full_time]

TRS Healthcare is seeking an experienced Intensive Care Unit Registered Nurse for an exciting Travel Nursing job in Los Angeles, CA.Shift: 3x12 hr nights Start Date: 04/06/2026 Duration: 13 weeks P...[show_more]

[last_updated.last_updated_variable_days] • [promoted]

Travel Nurse - RN - Case Manager - $2406.87 / Week

FlexCare • Santa Ana, CA, US

[job_card.full_time]

FlexCare is seeking an experienced Case Manager Registered Nurse for an exciting Travel Nursing job in Los Angeles, CA.Shift: 5x8 hr days Start Date: ASAP Duration: 13 weeks Pay: $2406.Why Clinicia...[show_more]

[last_updated.last_updated_30] • [promoted]

Travel Nurse - RN - SDU - Stepdown Unit - Hiring Now

Medical Solutions • Santa Ana, CA, US

[job_card.full_time]

Medical Solutions is seeking an experienced Stepdown Unit Registered Nurse for an exciting Travel Nursing job in Los Angeles, CA.Shift: 2x12 hr nights Start Date: ASAP Duration: 13 weeks.A facility...[show_more]

[last_updated.last_updated_30] • [promoted]

Travel Nurse RN - $65 per hour in Santa Ana, CA

TravelNurseSource • Santa Ana, CA, US

[job_card.full_time]

TravelNurseSource is working with Adelphi Medical Staffing to find a qualified Other RN in Santa Ana, California, 92701!.Adelphi is seeking a Registered Nurse (RN) to provide nursing services for a...[show_more]

[last_updated.last_updated_30] • [promoted]

Travel Nurse - RN - Outpatient Clinic - $2819 / Week

Lancesoft • Santa Ana, CA, US

[job_card.full_time]

Lancesoft is seeking an experienced Outpatient Clinic Registered Nurse for an exciting Travel Nursing job in Los Angeles, CA.Shift: 4x10 hr days Start Date: ASAP Duration: 13 weeks Pay: $2819 / Wee...[show_more]

[last_updated.last_updated_variable_days] • [promoted]

Travel Nurse - RN - Transplant - $4299 / Week - Hiring Now

Lancesoft • Santa Ana, CA, US

[job_card.full_time]

Lancesoft is seeking an experienced Transplant Registered Nurse for an exciting Travel Nursing job in Los Angeles, CA.Shift: 5x8 hr days Start Date: 03/23/2026 Duration: 13 weeks Pay: $4299 / Week....[show_more]

[last_updated.last_updated_variable_days] • [promoted]

Travel Nurse - RN - Case Manager - $2329.1 / Week - Hiring Now

Atlas MedStaff • Lakewood, CA, US

[job_card.full_time]

[last_updated.last_updated_variable_days] • [promoted]

Travel Nurse - RN - Transplant - $4299 / Week

Lancesoft • Santa Ana, CA, US

[job_card.full_time]

[last_updated.last_updated_variable_days] • [promoted]

Travel Nurse - RN - ICU - Intensive Care Unit - $2602 / Week

Pulse Healthcare Services • Santa Ana, CA, US

[job_card.full_time]

Pulse Healthcare Services is seeking an experienced Intensive Care Unit Registered Nurse for an exciting Travel Nursing job in Santa Ana, CA.Shift: 3x12 hr nights Start Date: ASAP Duration: 6 weeks...[show_more]

[last_updated.last_updated_30] • [promoted]

Travel Nurse - RN - Case Manager - $2395.27 / Week

FlexCare • Santa Ana, CA, US

[job_card.full_time]

[last_updated.last_updated_30] • [promoted]

Travel Nurse - RN - ICU - Intensive Care Unit - $2243 / Week - Hiring Now

MedPro Healthcare Staffing • Santa Ana, CA, US

[job_card.full_time]

MedPro Healthcare Staffing is seeking an experienced Intensive Care Unit Registered Nurse for an exciting Travel Nursing job in Los Angeles, CA.Shift: 3x12 hr nights Start Date: 04/06/2026 Duration...[show_more]

[last_updated.last_updated_variable_days] • [promoted]

Travel Nurse - RN - Outpatient Clinic - $2819 / Week - Hiring Now

Lancesoft • Santa Ana, CA, US

[job_card.full_time]

[last_updated.last_updated_variable_days] • [promoted]

Travel Nurse RN - $2,800 per week in Orange, CA

TravelNurseSource • Orange, CA, US

[job_card.full_time] +1

TravelNurseSource is working with Prime Staffing to find a qualified Other RN in Orange, California, 92856!.Active State or Compact RN License.BLS – AHA; Case Management certification (e.Strong com...[show_more]

[last_updated.last_updated_30] • [promoted]