Utilization Management Nurse Jobs in California
Utilization management nurse jobs in California are among the most active in the country, concentrated in managed care organizations, large integrated health systems, and health insurance carriers, with openings at every level from case management coordinators through senior UM nurse leads and directors. The highest volumes of listings come out of Los Angeles, San Francisco, and Sacramento, where employers such as Kaiser Permanente, Anthem Blue Cross of California, and Sutter Health consistently hire for these roles. The most in-demand specialties are behavioral health utilization review, Medicare and Medi-Cal managed care, and acute inpatient clinical review. Find a role that fits below and apply directly.
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Showing 5 of 20+ Utilization Management Nurse jobs
WHO WE ARE
NeueHealth is a value-driven healthcare company grounded in the belief that all health consumers are entitled to high-quality, coordinated care. By uniquely aligning the interests of health consumers, providers, and payors, we help to make healthcare accessible and affordable to all populations across the ACA Marketplace, Medicare, and Medicaid.
NeueHealth delivers clinical care to health consumers through our owned clinics – Centrum Health and Premier Medical – as well as unique partnerships with affiliated providers across the country. We also enable providers to succeed in performance-based arrangements through a suite of technology and services scaled centrally and deployed locally. Through our value-driven, consumer-centric approach, we are committed to transforming healthcare and creating a better care experience for all.
JOB SUMMARY
The Utilization Management (UM) Prior Authorization (PA) Nurse is a full-time role with NeueHealth, dedicated to promoting quality and cost-effective outcomes for the designated population. Working in collaboration with Medical Directors and the clinical team, the PA Nurse ensures members receive the appropriate benefit coverage for services requiring prior authorization. Responsibilities include reviewing prior authorizations for treatments, medications, procedures, and diagnostic tests to confirm alignment with contract requirements, coverage policies, and evidence-based medical necessity criteria. The PA Nurse also collects and analyzes utilization data and monitors the quality and appropriate use of services. This role demands clinical expertise, keen attention to detail, and strong communication skills to effectively engage with healthcare providers, patients, and health plans. The PA Nurse adheres to all standard operating procedures and organizational policies and consistently meets or exceeds established performance benchmarks.
DUTIES & RESPONSIBILITIES
1. Authorization and Review
o Evaluate and process prior authorization requests for medical procedures, medications, and services based on clinical guidelines such as: Medicare criteria, Medicaid/Medi-Cal criteria, InterQual, MCG, or Health Plan specific guidelines.
o Utilize clinical knowledge to assess medical necessity and appropriateness of requested services.
o Verify patient eligibility, benefits, and coverage details.
2. Collaboration and Communication
o Serve as a liaison between healthcare providers, patients, and health plans to facilitate the authorization process.
o Communicate authorization decisions to the requesting provider and/or patient in a timely manner.
o Provide detailed explanations of denials or alternative solutions when authorization is not granted.
o Collaborate with the Medical Directors as needed to ensure all information is considered prior to an adverse determination.
o When an adverse determination is rendered, collaborate with the Medical Director to ensure integrity of determination notices based on the quality standards for adverse determinations.
o Comply with federal, state, and health plan specific requirements related to member communication of adverse determinations to include preferred language, mandated readability standard, correct medical criteria is referenced and the appropriate appeal information is provided.
3. Documentation and Compliance
o Accurately document all authorization-related activities in the electronic medical record (EMR) or authorization management system.
o Ensure compliance with federal, state, and health plan specific regulations and guidelines.
o Maintain knowledge of evolving policy and clinical criteria.
4. Quality Improvement
o Identify trends or recurring issues in authorization denials and recommend process improvements.
o Participate in team meetings, training sessions, and audits to ensure high-quality performance.
QUALIFICATIONS
- Education:
o Bachelor of Science in Nursing (BSN) preferred but not required.
o Certification Managed Care Nursing (CMCN) preferred.
- Experience:
o Familiarity with insurance authorization processes, medical billing, and coding (e.g., ICD-10, CPT codes).
o Working knowledge of MCG, InterQual, and NCQA standards.
- Skills:
o Proficient in medical terminology and pharmacology.
o Effective written and verbal communication skills.
o Ability to work independently and collaboratively in a fast-paced environment.
o Highly adaptable to change and self-motivated.
- Technology:
o Proficient in Microsoft Office Suite (Word, Excel, Outlook).
For individuals assigned to a location(s) in California, NeueHealth is required by law to include a reasonable estimate of the compensation range for this position. Actual compensation will vary based on the applicant's education, experience, skills, and abilities, as well as internal equity. A reasonable estimate of the range is $74,286.15-$111,429.23 Annually.
Additionally, employees are eligible for health benefits; life and disability benefits, a 401(k) savings plan with match; Paid Time Off, and paid holidays.
As an Equal Opportunity Employer, we welcome and employ a diverse employee group committed to meeting the needs of NeueHealth, our consumers, and the communities we serve. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law.
WHO WE ARE
NeueHealth is a value-driven healthcare company grounded in the belief that all health consumers are entitled to high-quality, coordinated care. By uniquely aligning the interests of health consumers, providers, and payors, we help to make healthcare accessible and affordable to all populations across the ACA Marketplace, Medicare, and Medicaid.
NeueHealth delivers clinical care to health consumers through our owned clinics – Centrum Health and Premier Medical – as well as unique partnerships with affiliated providers across the country. We also enable providers to succeed in performance-based arrangements through a suite of technology and services scaled centrally and deployed locally. Through our value-driven, consumer-centric approach, we are committed to transforming healthcare and creating a better care experience for all.
JOB SUMMARY
The Utilization Management (UM) Prior Authorization (PA) Nurse is a full-time role with NeueHealth, dedicated to promoting quality and cost-effective outcomes for the designated population. Working in collaboration with Medical Directors and the clinical team, the PA Nurse ensures members receive the appropriate benefit coverage for services requiring prior authorization. Responsibilities include reviewing prior authorizations for treatments, medications, procedures, and diagnostic tests to confirm alignment with contract requirements, coverage policies, and evidence-based medical necessity criteria. The PA Nurse also collects and analyzes utilization data and monitors the quality and appropriate use of services. This role demands clinical expertise, keen attention to detail, and strong communication skills to effectively engage with healthcare providers, patients, and health plans. The PA Nurse adheres to all standard operating procedures and organizational policies and consistently meets or exceeds established performance benchmarks.
DUTIES & RESPONSIBILITIES
1. Authorization and Review
o Evaluate and process prior authorization requests for medical procedures, medications, and services based on clinical guidelines such as: Medicare criteria, Medicaid/Medi-Cal criteria, InterQual, MCG, or Health Plan specific guidelines.
o Utilize clinical knowledge to assess medical necessity and appropriateness of requested services.
o Verify patient eligibility, benefits, and coverage details.
2. Collaboration and Communication
o Serve as a liaison between healthcare providers, patients, and health plans to facilitate the authorization process.
o Communicate authorization decisions to the requesting provider and/or patient in a timely manner.
o Provide detailed explanations of denials or alternative solutions when authorization is not granted.
o Collaborate with the Medical Directors as needed to ensure all information is considered prior to an adverse determination.
o When an adverse determination is rendered, collaborate with the Medical Director to ensure integrity of determination notices based on the quality standards for adverse determinations.
o Comply with federal, state, and health plan specific requirements related to member communication of adverse determinations to include preferred language, mandated readability standard, correct medical criteria is referenced and the appropriate appeal information is provided.
3. Documentation and Compliance
o Accurately document all authorization-related activities in the electronic medical record (EMR) or authorization management system.
o Ensure compliance with federal, state, and health plan specific regulations and guidelines.
o Maintain knowledge of evolving policy and clinical criteria.
4. Quality Improvement
o Identify trends or recurring issues in authorization denials and recommend process improvements.
o Participate in team meetings, training sessions, and audits to ensure high-quality performance.
QUALIFICATIONS
- Education:
o Bachelor of Science in Nursing (BSN) preferred but not required.
o Certification Managed Care Nursing (CMCN) preferred.
- Experience:
o Familiarity with insurance authorization processes, medical billing, and coding (e.g., ICD-10, CPT codes).
o Working knowledge of MCG, InterQual, and NCQA standards.
- Skills:
o Proficient in medical terminology and pharmacology.
o Effective written and verbal communication skills.
o Ability to work independently and collaboratively in a fast-paced environment.
o Highly adaptable to change and self-motivated.
- Technology:
o Proficient in Microsoft Office Suite (Word, Excel, Outlook).
For individuals assigned to a location(s) in California, NeueHealth is required by law to include a reasonable estimate of the compensation range for this position. Actual compensation will vary based on the applicant's education, experience, skills, and abilities, as well as internal equity. A reasonable estimate of the range is $74,286.15-$111,429.23 Annually.
Additionally, employees are eligible for health benefits; life and disability benefits, a 401(k) savings plan with match; Paid Time Off, and paid holidays.
As an Equal Opportunity Employer, we welcome and employ a diverse employee group committed to meeting the needs of NeueHealth, our consumers, and the communities we serve. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law.
See All 20 Utilization Management Nurse Jobs in California
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Find JobsUtilization Management Nurse Jobs by City in California
Where California roles are concentrated, by current openings.
Utilization Management Nurse Job Market in California
A snapshot from current California openings, updated as new roles post.
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What California Employers Look For
The qualifications that appear most often in utilization management nurse jobs across California.
- Active California Registered Nurse license issued by the California Board of Registered Nursing
- Minimum two years of acute care or managed care clinical nursing experience
- Working knowledge of InterQual or Milliman clinical decision-support criteria
- Familiarity with Medicare, Medi-Cal, or commercial managed care authorization processes
- Strong written communication skills for clinical documentation and denial letter writing
- Certification in case management such as CCM or CMCN preferred by most California employers
Utilization Management Nurse Jobs in California: Frequently Asked Questions
How do you become a utilization management nurse in California?
You must first hold an active Registered Nurse license issued by the California Board of Registered Nursing, which requires completing an accredited nursing program and passing the NCLEX-RN. From there, most California employers expect at least two years of clinical nursing experience before moving into a UM role. Adding a case management certification such as the CCM strengthens your candidacy, and many California health plans and hospital systems prefer candidates who have worked in acute care, med-surg, or a managed care setting beforehand.
Which companies hire utilization management nurses in California?
Employers hiring utilization management nurses in California right now include PIH Health, Alignment Healthcare, and Prime Healthcare Services, based on current listings on Migrate Mate as of August 2026. California's large integrated health systems and managed care organizations account for most of the volume, reflecting the state's concentration of commercial and Medi-Cal health plan activity.
Which California cities have the most utilization management nurse jobs?
The cities with the most utilization management nurse openings in California are Los Angeles, California, and Downey. Los Angeles leads because of its dense concentration of large health plans and hospital systems, while San Francisco and Sacramento reflect the headquarters presence of major managed care organizations and state government health programs such as Medi-Cal that drive steady UM staffing demand across Northern California.
Are there remote utilization management nurse jobs in California?
Yes, and more than most nursing roles. Utilization management is desk-based and chart-driven, which makes it well suited to remote and hybrid arrangements compared to bedside or procedural nursing. About 100% of utilization management nurse openings tied to California are remote or hybrid as of August 2026, reflecting how broadly California health plans have adopted distributed UM teams. Prior authorization review and concurrent inpatient reviews are the functions most commonly offered remotely.
How can I get hired as a utilization management nurse in California with little or no experience?
The most realistic entry path is moving from a clinical bedside role into a UM associate or clinical reviewer position within a large California health system or health plan. Kaiser Permanente and Sutter Health run internal transition programs that allow RNs from med-surg or case management to cross-train into utilization review. Starting as a care coordinator or discharge planner at a California acute care hospital builds the chart review and criteria application skills that UM teams prioritize. Holding an active California RN license and completing an introductory case management course gives candidates a clear edge when applying without direct UM experience.
Where can I find and apply to utilization management nurse jobs in California?
You can find and apply to utilization management nurse jobs in California on Migrate Mate, which lists current California openings. Search the listings to find roles that match your experience, specialization, and preferred location or work arrangement, then apply directly to the ones that fit.
See All 20 Utilization Management Nurse Jobs in California
Find roles in California that match your experience and apply in just a few clicks.
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