UM Nurse, Pre-service – California RN/LVN License Required

This is a fully remote position, open to applicants in California.

📋 Description

• Assess pre-certification requests to determine medical necessity and refer to the medical director for any cases requiring specialized expertise.

• Apply CMS guidelines (LCD, NCD) to aid in referral determinations and utilize Milliman Care Guidelines (MCG) for assistance in referrals.

• Adhere to established goals for turnaround time (TAT) in referral processing.

• Initiate single service agreements (SSA) when necessary services are unavailable in-network.

• Foster a professional relationship with providers, physicians, support staff, and patients to ensure efficient processing of pre-certification referrals.

• Confirm eligibility and/or benefit coverage for the requested services.

• Ensure accuracy of ICD 10 and CPT coding when processing pre-certification requests.

• Communicate with the requesting provider to obtain medical records, orders, and/or necessary documentation for processing related pre-service requests and authorizations when needed.

• Examine referral denials for compliance with appropriate guidelines and language.

• Aid medical directors in reviewing and addressing appeals and grievances.

• Reach out to members and maintain call documentation for expedited requests.

• Perform other duties as assigned.

⛳️ Requirements

• At least three (3) years of nursing experience in a clinical environment.

• A minimum of one (1) year of experience in Utilization Management (UM) with pre-service.

• At least one (1) year of experience in managed care (Medicaid and/or Medicare).

• Minimum of one (1) year of experience applying UM criteria (e.g., CMS National and Local Coverage Determinations, etc.).

• A minimum of one (1) year of experience in a medical setting working with Independent Practice Associations (IPAs), entering referrals/prior authorizations preferred.

• At least one (1) year of experience utilizing clinical criteria, specifically Milliman Care Guidelines (MCG).

• Must possess and maintain an active, valid, and unrestricted LVN or RN license in California (Non-Compact).

• Upon hire, must be willing to obtain LVN and/or RN licensure in Nevada (Non-Compact), Arizona (Compact), North Carolina (Compact), and Texas (Compact), with costs reimbursed by the company.

• Preferred: CPHQ or ABQAURP certification, or Six Sigma certification, along with a Medical Terminology Certificate.

• Required: None

🏝️ Benefits

• Health insurance

• Flexible work arrangements

• Opportunities for professional development