Outpatient Review Nurse

This is a fully remote position, open to applicants in California, +1 more state.

📋 Description

• Evaluate authorization requests for medical necessity and identify those requiring Medical Director review.

• Gather adequate medical documentation to enable informed evaluations.

• Process all requests within the designated timeframes.

• Record all procedural steps in the authorization system notes.

• Apply CMS and Health Plan Hierarchy criteria.

• Compile clinical documentation, specific criteria, and record attachments for Medical Director referrals.

• Perform retrospective reviews of services to assess medical necessity.

• Escalate cases to the Medical Director when requests may not fulfill medical necessity criteria.

• Manage denials within set timeframes.

• Draft denial letters that comply with CMS and Health Plan standards.

• Utilize clinical criteria, guidelines, policies, benefit policies, and clinical judgment to make coverage decisions or recommendations.

• Analyze member utilization and claim history during the referral process.

• Uphold quality reviews while adhering to turnaround times for urgent, routine, and retrospective requests.

• Maintain an Interrater Reliability Rate of at least 95%.

• Achieve a daily production target of 50–90 referrals per day, contingent on complexity, accuracy, and quality.

• Make approval decisions when requests align with appropriateness, medical necessity, and benefit criteria.

• Evaluate, plan, implement, coordinate, monitor, and assess healthcare service options.

• Serve as a clinical resource across all departments.

• Communicate with health plans, providers, members, and other stakeholders to support member care treatment plans.

• Engage in team training sessions.

• Adhere to UM policies and procedures and participate in provider and interdepartmental meetings.

• Uphold strict confidentiality while managing sensitive provider and member information.

• Perform additional duties as required.

⛳️ Requirements

• A valid Registered Nurse license in CA and Texas/Multi State or a Licensed Vocational Nurse.

• Current unrestricted RN or LVN license in CA and Texas/Multi State.

• Training and/or certification in Case Management (CM) and/or Utilization Management (UM).

• Familiarity with CM standards, UM standards, Clinical Standards of Care, NCQA requirements, CMS guidelines, Milliman guidelines, and InterQual guidelines.

• Preferred knowledge of Medi-Cal, Commercial, and Medicare contracts and benefit interpretation.

• Over five years of clinical experience.

• Preferred and recommended two years of experience in an HMO / IPA / Managed care setting.

• Must be available to work weekends and holidays as required by business needs.

• Capability to work independently with minimal supervision, demonstrating sound judgment and initiative.

• Skill in managing multiple tasks with effective prioritization.

• Proficient in using Outlook, Microsoft Teams, Zoom, Microsoft Office (including Word and Excel), and Adobe.

• Detail-oriented and exceptionally organized.

• Strong ability to multitask, manage projects, and thrive in a fast-paced environment.

• Excellent problem-solving skills.

• Strong self-management and time-management abilities.

• Capacity to work in a highly confidential environment.

• Excellent written and verbal communication skills.

🏝️ Benefits

• 100% employer-funded medical, vision, dental, and life insurance coverage.

• Additional options for employee-paid coverage.

• Paid holidays.

• Day off for your birthday.

• Unlimited Paid Time Off (PTO).

• 401k retirement plan.

• Fully remote work setting.

• Flexible work environment and schedules.