• Job Description

  Req#: 26-01823
  
  
  Ampcus Inc. is a certified global provider of a broad range of Technology and Business consulting services. We are in search of a highly motivated candidate to join our talented Team.
  Job Title: Utilization Management Technician
  Location(s): Los Angeles, CA
  (Remote)
  
  
  Position Summary
  We are seeking an experienced Utilization Management Review Nurse with strong outpatient prior authorization experience in a health plan or managed care environment. The ideal candidate is a California-licensed RN who can independently review clinical documentation, apply evidence-based medical necessity criteria, and make timely authorization determinations in a high-volume setting.
  This role requires confident communication with physicians, payers, and internal teams, strong critical-thinking skills, and in-depth knowledge of Medicare, Medi-Cal, and CCS utilization review requirements.
  
  Key Responsibilities
  • Review and evaluate clinical documentation for outpatient prior authorization requests
  • Apply evidence-based medical necessity criteria (InterQual, Milliman, CMS, and health plan–specific guidelines).
  • Determine approval, denial, modification, or need for physician review.
  • Communicate authorization decisions clearly to physicians, clinical staff, payers, and internal departments.
  • Collaborate with physician reviewers and interdisciplinary clinical teams to resolve authorization requests.
  • Abstract and interpret medical records to support utilization review decisions.
  • Act as a clinical resource for customer service, claims, and internal stakeholders.
  • Manage a high-volume caseload in a fast-paced remote environment.
  • Participate in performance improvement initiatives and other assigned duties.
  Required Qualifications
  • Current, unrestricted Registered Nurse (RN) license in California.
  • 3–5 years of utilization management and/or outpatient prior authorization experience.
  • Health plan, managed care organization, IPA, MSO, or healthcare plan administrator experience (required).
  • Demonstrated ability to independently assess medical necessity and level of care.
  • Strong knowledge of Medicare, Medi-Cal, and CCS utilization review regulations.
  • Proficiency with evidence-based medical necessity criteria (InterQual, Milliman, CMS).
  • Strong written and verbal communication skills with clinical and non-clinical audiences.
  • Proven ability to prioritize and manage workload in a high-volume environment.
  • Proficient computer skills (Microsoft Word, Excel, internet navigation, and managed care systems such as EZ-Cap, Diamond, IDX)
  Preferred Skills & Competencies
  • Strong critical thinking, analytical, and problem-solving skills.
  • Ability to work collaboratively with interdisciplinary clinical teams.
  • Skill in abstracting and interpreting complex medical records.
  • Clinical background sufficient to explain diagnoses and treatment plans to diverse audiences.
  • Resourceful, self-directed, and organized with strong attention to detail
  Must Have
  • Outpatient prior authorization experience.
  • Health plan or healthcare plan administrator background.
  • Experience as a Prior Authorization Nurse / Clinical Review Nurse.
  Ampcus is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, protected veterans or individuals with disabilities.
  
  

• About the company

  Ampcus Inc. is an ISO 20000, ISO 27000, ISO 9001, CMMI DEV/3 SM, and CMMI SVC/3 SM certified global provider of a broad range of Technology and Business consulting services. From strategy to execution, our disciplined yet flexible approach starts and ends with our clients. By listening hard and working harder, client goals become our goals.

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