Utilization Management Nurse - Medicare
Remote | California RN Required | Must sit in CA
We're partnering with a mission‑driven healthcare organization seeking an experienced Utilization Management Nurse to support Medicare members across inpatient settings. This role plays a critical part in ensuring medically appropriate, cost‑effective care while supporting safe and timely discharge planning.
What You'll Do
-
Perform prospective, concurrent, and retrospective utilization reviews for Medicare members
-
Apply evidence‑based clinical guidelines (CMS, nationally recognized criteria, and payer policies) to determine medical necessity
-
Review inpatient admissions, ongoing stays, transfers, and out‑of‑network cases
-
Collaborate on discharge planning, including post‑acute needs and durable medical equipment
-
Prepare and present complex cases to a Medical Director for secondary review
-
Communicate determinations clearly and compliantly to providers and members
-
Identify potential quality‑of‑care concerns, treatment delays, or service gaps and intervene as appropriate
-
Maintain accurate, member‑centered documentation in compliance with regulatory and accreditation standards
-
Partner with Case Management when inpatient needs impact discharge
-
Meet assigned quality and productivity metrics
-
Participate in clinical rounds, team meetings, and support onboarding of new team members
-
Maintain a HIPAA‑compliant home work environment
What We're Looking For
-
Active California RN license (required)
-
BSN preferred (or higher nursing degree)
-
5+ years of relevant clinical or utilization management experience
-
Strong background in inpatient utilization review and medical necessity determination
-
Experience working with Medicare populations
-
Excellent clinical judgment, critical thinking, and decision‑making skills
-
Strong written and verbal communication abilities
-
Comfortable navigating multiple systems and working independently in a remote setting
Why This Role
-
Make a measurable impact on quality, access, and cost‑effective care
-
Fully remote role supporting California members
-
Collaborative UM and Medical Director partnership
-
Mission‑focused organization committed to ethical, patient‑centered care
Job Type & Location
This is a Contract to Hire position based out of Rancho Cordova, CA.
Pay and Benefits
The pay range for this position is $45.00 - $50.00/hr.
Eligibility requirements apply to some benefits and may depend on your job classification and length of employment. Benefits are subject to change and may be subject to specific elections, plan, or program terms. If eligible, the benefits available for this temporary role may include the following: - Medical, dental & vision - Critical Illness, Accident, and Hospital - 401(k) Retirement Plan - Pre-tax and Roth post-tax contributions available - Life Insurance (Voluntary Life & AD&D for the employee and dependents) - Short and long-term disability - Health Spending Account (HSA) - Transportation benefits - Employee Assistance Program - Time Off/Leave (PTO, Vacation or Sick Leave)
Workplace Type
This is a fully remote position.
Application Deadline
This position is anticipated to close on May 28, 2026.
About Actalent
Actalent is a global leader in engineering and sciences services and talent solutions. We help visionary companies advance their engineering and science initiatives through access to specialized experts who drive scale, innovation and speed to market. With a network of almost 30,000 consultants and more than 4,500 clients across the U.S., Canada, Asia and Europe, Actalent serves many of the Fortune 500.
The company is an equal opportunity employer and will consider all applications without regard to race, sex, age, color, religion, national origin, veteran status, disability, sexual orientation, gender identity, genetic information or any characteristic protected by law.
If you would like to request a reasonable accommodation, such as the modification or adjustment of the job application process or interviewing process due to a disability, please email actalentaccommodation@actalentservices.com for other accommodation options.
San Francisco Fair Chance Ordinance: Pursuant to the San Francisco Fair Chance Ordinance, for all positions located in the city and county of San Francisco, we will consider for employment qualified applicants with arrest and conviction records.
Massachusetts Lie Detector: It is unlawful in Massachusetts to require or administer a lie detector test as a condition of employment or continued employment. An employer who violates this law shall be subject to criminal penalties and civil liability.
Use of Artificial Intelligence (AI): We may use Artificial Intelligence (AI) to support parts of our hiring process, including sourcing, screening, and evaluating candidates. AI helps assess applications and qualifications, but final decisions are made by our hiring team. By applying, you acknowledge and agree that your application may be reviewed using AI tools.
