📍 Location: Alhambra, CA, US
🏠 Work: On-site
💰 Salary: USD 43 - 53 (hourly)
📝 Description: **Position Summary**
The PACE Utilization Review Specialist – RN oversees clinical utilization management for participants enrolled in the Program for All\\-Inclusive Care for the Elderly. The position ensures that services are medically appropriate, cost\\-effective, and coordinated. This role works closely with the PACE Medical Director and interdisciplinary team to review clinical cases, manage utilization policies, and ensure regulatory compliance.
**Essential Duties and Responsibilities**
* Conduct concurrent and retrospective utilization reviews for acute, post\\-acute, and outpatient services.
* Review clinical documentation and determine appropriate levels of care based on evidence\\-based criteria.
* Manage inpatient and post\\-acute length of stay and coordinate timely discharge planning.
* Review, develop, and implement utilization management policies and workflows.
* Prepare and present clinical case summaries and recommendations to internal leadership.
* Serve as a resource for primary care providers and care managers on utilization and authorization requirements.
* Ensure appropriate service authorization for hospitalizations, referrals, and specialty services.
* Communicate with providers, payers, and internal teams regarding claim adjudication and payment status.
* Identify high\\-risk participants and coordinate with clinical leadership on care strategies.
* Track and report utilization metrics and trends to support program improvement.
* Oversee denial management processes and provider appeal reviews.
* Document all utilization management activities in the electronic medical record.
* Participate in interdisciplinary team meetings and care planning sessions.
* Support staff education and training on utilization management policies and standards.
**Minimum Qualifications**
* Graduate of an accredited school of nursing with a current unencumbered Registered Nurse license in the State of California.
* Current BLS certification from the American Heart Association.
* Valid California driver’s license and acceptable driving record.
* Minimum three years of managed care experience, including one year in utilization management, case management, or care coordination.
* Minimum one year of experience working with the frail or elderly population.
* Strong analytical skills with the ability to evaluate clinical documentation and apply evidence\\-based criteria.
* Knowledge of State and Federal healthcare regulations, quality standards, and utilization review principles and guidelines such as Medicare, Medicaid and MCG/InterQual.
* Proficient in Microsoft Office, including advanced Excel skills.
* Excellent communication skills, both written and verbal.
* Demonstrated ability to work collaboratively across multidisciplinary teams.
**Preferred Qualifications**
* Bachelor of Science in Nursing (BSN) strongly preferred.
* Certified Case Manager (CCM) or Certified Professional in Healthcare Management (CPHM) preferred.
**Physical Demands and Work Environment**
* Requires standing, walking, occasional pushing, pulling, and lifting.
* Ability to lift up to 30 pounds; assistance required for heavier loads.
* Manual dexterity and visual/hearing acuity required for clinical assessment and documentation.
* Exposure to infectious materials and biohazards common in healthcare settings.
* Must be able to communicate with participants, caregivers, and team members, including those with cognitive or physical limitations.
* Moderate stress related to deadlines, caseload volume, and patient conditions.
**Direct Reports**
PACE Medical Director
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