Initial Clinical Reviewer

• RN Case Manager IMS Cost Containment Lake Forest, CA Job Details Full-time $78,000
• $88,000 a year 5 hours ago Benefits Health savings account Health insurance Dental insurance 401(k) Flexible spending account Paid time off Vision insurance 401(k) matching Flexible schedule Life insurance Qualifications Microsoft Word Computer operation Nursing Utilization review RN License Workers' compensation insurance knowledge Bachelor's degree Utilization management Medical treatment knowledge Desktop applications Resource utilization in healthcare CPT coding Organizational skills Workers' compensation Regulatory compliance analysis Legal compliance Technical Proficiency Nursing Full Job Description Position Overview Intelligent Medical Solutions (IMS) is seeking an experienced Registered Nurse (RN) to serve as an Initial Clinical Reviewer•RN Case Manager specializing in Workers' Compensation Utilization Review .

This role is 100% located within our office in Lake Forest, CA and applies clinical expertise and evidence-based criteria to evaluate the medical necessity of provider treatment requests. The ideal candidate has strong experience in utilization review within the Workers' Compensation environment and thrives in a fast-paced, deadline-driven setting, familiar with CPT, HPCS, Carve outs, and Bill Review. Key Responsibilities Perform prospective, concurrent, and retrospective utilization reviews in accordance with state-specific Workers' Compensation guidelines. Apply clinical judgment and established medical criteria to determine medical necessity. Authorize treatment when appropriate or escalate cases to physician reviewers with clear clinical rationale. Ensure compliance with mandated turnaround times and regulatory requirements. Maintain up-to-date knowledge of state-specific UR regulations. Accurately document review determinations and maintain quality tracking data. Produce professional, compliant, and high-quality review reports. Respond to utilization management-related calls in a professional and knowledgeable manner. Collaborate with the IMS UR team and participate in department meetings and committees. Provide mentorship and guidance to new or junior clinical reviewers as needed. Required Qualifications Graduate of an accredited School of Nursing. Active RN license in a U.S. state or territory, recognized in the applicable jurisdiction. The license must be unrestricted; if it is restricted in a way the jurisdiction allows, the restriction must not affect the ability to perform the duties of the position. Minimum 3 years of clinical nursing experience. Demonstrated professional and technical skills of an RN. Minimum 2 years of Utilization Review experience. Minimum 3 years of Workers' Compensation experience. Experience in IT-related clinical roles such as Data Analyst or Clinical Documentation Improvement (CDI). Strong understanding of medical necessity guidelines and regulatory compliance. Excellent written and verbal communication skills. Excellent interpersonal skills and strong organizational skills. High proficiency with computers, including MS Word, MS Excel, email, and case management systems. Ability to work independently with minimal supervision. Ability to meet strict deadlines in a high-volume, high-pressure, time-sensitive environment. Preferred Education Bachelor's Degree in Nursing (BSN) preferred or Related Field Physical Requirements Prolonged sitting and computer use. Frequent use of hands and fingers. Occasional lifting up to 20 lbs. Ability to meet vision requirements including close and distance vision. Reasonable accommodations may be made to enable individuals with disabilities to perform essential functions. Benefits 401(k) with employer matching Health, Dental, and Vision Insurance Health Savings Account (HSA) Flexible Spending Account (FSA) Life Insurance Paid Time Off Education Assistance Opportunities Company provided equipment: Computer, Monitors, Etc.

Pay:

$78,000.00

• $88,000.

00 per year

Benefits:

401(k) 401(k) matching Dental insurance Flexible schedule Flexible spending account Health insurance Health savings account Life insurance Paid time off Vision insurance

Education:

Bachelor's (Preferred)

Experience:

Utilization review: 2 years (Required) IT Experience

• data analyst or

CDI:

2 years (Required) Workers' compensation: 3 years (Required)

License/Certification:

RN License (Required)

Work Location:

In person