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Senior Utilization Management Nurse Job Summary The Senior Utilization Management Nurse reviews facility claims for contract compliance, billing accuracy, medical necessity, and hospital-acquired conditions. This role reviews medical records and applies clinical criteria to determine the appropriate level of care. The position also conducts detailed, line-by-line audits of hospital bills and processes claim exceptions according to facility-specific contract requirements. Responsibilities Perform retrospective utilization reviews and first-level determinations using evidence-based guidelines, policies, and nationally recognized clinical criteria. Conduct clinical reviews of claims for medical necessity, coding accuracy, medical policy compliance, and contract compliance. Prepare and present cases to the Medical Director for oversight and medical necessity determinations. Communicate determinations to providers and members in compliance with applicable regulatory and accreditation requirements. Prepare and review member-centered documentation and correspondence reflecting clinical determinations. Identify potential quality-of-care issues, treatment delays, and service concerns, and intervene when clinically appropriate. Review itemized hospital bills for coding accuracy and billing logic using industry standards and applicable regulatory guidelines. Audit claims involving medical necessity, diagnosis-related groups, stop-loss provisions, trauma, emergency services, burns, implants, neonatal intensive care, transplants, hospital-acquired conditions, and unusual billing patterns. Triage and prioritize cases to meet required turnaround times. Apply clinical judgment and detailed knowledge of benefit plans to support review decisions. Communicate clearly and collaborate effectively while maintaining efficiency and accuracy. Requirements Current California Registered Nurse license. At least five years of relevant professional experience. Strong computer navigation and documentation skills. Ability to work independently with strong motivation and work ethic. Managed care experience, including inpatient claims or concurrent review, preferred. Skill Utilization management and retrospective clinical review Medical necessity and level-of-care determination Claims auditing and coding accuracy review Contract and regulatory compliance Clinical documentation and case presentation Knowledge of benefit plans and clinical guidelines Prioritization, communication, and collaboration Summary Qualification Licensed Registered Nurse in California with at least five years of relevant experience. Experience reviewing medical records, hospital claims, itemized bills, and clinical documentation. Knowledge of medical necessity criteria, coding standards, benefit plans, and managed care processes. Strong independent judgment, attention to detail, communication skills, and computer proficiency. Wollborg Michelson Recruiting is an Equal Opportunity Employer and prohibits discrimination of any kind. We ensure job offers are made based of one s employment experience, skills, and qualifications, regardless of race, gender, ethnic origin, or any other classification protected by law. All applicants must furnish proper identification to prove their legal right to work in the US upon a job offer. We participate in E-Verify to confirm one s right to work in the US. Wollborg Michelson Recruiting does not provide sponsorship for an employment-based visa status.