UM Nurse, RN

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

📋 Description

• Assess and process prior authorization requests for medical services, medications, and procedures utilizing guidelines from Medicare, Medicaid/Medi-Cal, InterQual, MCG, or specific health plans.

• Evaluate the medical necessity and appropriateness of requested services through clinical expertise.

• Confirm patient eligibility, benefits, and coverage information.

• Act as a liaison among healthcare providers, patients, and health plans to streamline the authorization process.

• Convey authorization decisions and clarify denials or provide alternative options.

• Collaborate with Medical Directors prior to making adverse determinations and ensure that determination notices adhere to quality standards.

• Adhere to federal, state, and health plan regulations for communicating adverse determinations.

• Record authorization activities in electronic medical records (EMR) or authorization management systems.

• Ensure compliance with relevant regulations, guidelines, policies, and evolving clinical criteria.

• Recognize trends in authorization denials and suggest improvements to processes.

• Engage in team meetings, training sessions, and audits.

• Achieve or surpass established performance benchmarks.

⛳️ Requirements

• Valid California license as a Registered Nurse (RN).

• Bachelor of Science in Nursing (BSN) is preferred, though not mandatory.

• Certification in Managed Care Nursing (CMCN) is preferred.

• At least 2 years of clinical nursing experience, ideally in utilization management, case management, or prior authorizations.

• Knowledge of insurance authorization procedures, medical billing, and coding, including ICD-10 and CPT codes.

• Familiarity with MCG, InterQual, and NCQA standards.

• Strong analytical and critical thinking abilities.

• Competence in medical terminology and pharmacology.

• Excellent written and verbal communication skills.

• Capability to work both independently and as part of a team in a fast-paced setting.

• Highly adaptable to change and self-driven.

• Experience with EMR systems and prior authorization platforms.

• Proficient in Microsoft Office Suite, including Word, Excel, and Outlook.

🏝️ Benefits

• Full-time employment.

• Equal opportunity employment.