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Utilization Review Nurse

Utilization Review Nurse

Job Description

Consider a career at Santa Clara Family Health Plan a public, not-for-profit plan of over 190,000 members.  

We are seeking a Utilization Review Nurse who will be responsible for the day-to-day utilization review for inpatient and outpatient activities, utilizing approved policies, standards, and clinical criteria.



  1. Analyze and evaluate medical records and other health data to make medical necessity determinations within required turn-around times and provide review outcomes to members and providers as per appropriate notification standards.
  2. Implement the Utilization Management (UM) processes and coordinate medical services with other SCFHP departments, as well as local and state healthcare initiatives, e.g., CBAS, Regional Center, and others.
  3. Review outpatient prior authorization requests and/or retrospective requests through claims review and incoming requests to ensure medical necessity for services requiring preauthorization.
  4. Contribute to the development of prior authorization criteria for establishing medical necessity based on nationally published clinical reference and standards of practice.
  5. Participate in the development and implementation of interventions that address identified target areas to improve health status of SCFHP members.
  6. Perform concurrent and retrospective review of inpatient, SNF, and Home Health members. Coordinate with specialized vendors, hospital discharge planning staff, and providers. May include onsite activities.
  7. Contribute to delegation oversight of the UM Program with the delegated provider networks and/or the auditing of these entities.
  8. In collaboration with the department, manage the UM phone queue during business hours.
  9. Work with internal tools and other department resources as needed to create reports on UM activities; provide analysis and present reports and analysis to various SCFHP committees.
  10. Perform data entry into system software applications for authorization and determination.
  11. Attend and participate in, including preparation for and follow up on, the reporting and coordination of the UM Committee meetings.
  12. Implement and participate in the documentation of the UM program, work plan, and annual evaluation including any other submission to the appropriate regulatory bodies.
  13. In conjunction with the team, manage the MOU relations and meetings with external entities.
  14. Support departmental and company goals and mission.
  15. Performs other duties, projects or functions as assigned.  

Job Requirements


  1. Minimum current California  Licensed Vocational Nurse (LVN) 
  2. Minimum 2 years’ Medical/Surgical clinical nursing experience.
  3. Minimum 1 year in Managed Care, UM, or Case Management. (Desired)
  4. Current working knowledge of Medicare and Medi-Cal guidelines and regulations. (Desired)
  5. Excellent organizational, written, and interpersonal skills
  6. Competent at the intermediate level or higher with computer application programs such as MS Word, Excel, Power Point, and Access.
  7. Self-directed with proven ability to work independently under general direction and minimal supervision; able to assume responsibility, take initiative, follow up on assignments, make appropriate decisions within the scope of the position, handle multiple projects simultaneously and assume accountability for own errors.
  8. Able to communicate in a professional manner with a variety of personnel, physicians, vendors and to remain calm when dealing with aggravated and/or aggressive callers.
  9. Possess a valid California Driver License, with access to a reliable vehicle with automobile insurance, or the ability to provide alternate transportation, if prohibited by a medically documented disability from obtaining a Driver License, to travel within Santa Clara County.



Santa Clara Family Health Plans offers a comprehensive benefits package including PTO, holidays, fitness center membership, medical, dental and vision coverage, CalPERS retirement, 401a and 457 Deferred Compensation retirement plans.


Contact Information

To view the full job description or to apply please visit our careers page at


SCFHP is an Equal Opportunity Employer.

Job Snapshot

Employment Type Full-Time
Job Type Health Care
Education 2 Year Degree
Experience At least 2 year(s)
Manages Others Not Specified
Industry Healthcare - Health Services
Required Travel Not Specified
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Utilization Review Nurse

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