Utilization Management Nurse, LVN – Casual

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

📋 Description

• Collaborate with external agencies and representatives regarding the utilization management process, which includes health plans, medical providers, vendors, and CMS.

• Conduct Utilization Review activities either prospectively or retrospectively for elective/urgent hospital admissions and outpatient services as outlined on the Prior Authorization List, ensuring comprehensive and timely reports to members, providers, and health plans as needed.

• Support medical directors in benefit interpretation, gather additional medical necessity information, and investigate concerns.

• Partner closely with physicians, other healthcare and service providers, health plan representatives, care management staff, and UM Coordinators to facilitate medical management for incoming authorization requests.

• Assess the authorization request and medical information submitted by the requesting provider for medical necessity and appropriateness, aligning the information with current medical care criteria set by health plans and as mandated by BTP, CMS, CDC, NCQA, and DMHC requirements.

⛳️ Requirements

• LVN - Licensed Vocational Nurse of California Licensure is mandatory.

• Familiarity with healthcare reimbursement systems such as HMO, PPO, PPS, CMA, all value-based reimbursement models, and alternative payment systems is preferred.

• A minimum of 2 years of recent relevant experience is required.

• Recent experience with MCG or InterQual is highly desirable.

• Knowledge of ICD-9, CPT, and HCPCS codes is preferred.

🏝️ Benefits

• Outstanding medical, vision, and dental coverage.

• 401(k) savings plan with a company match.

• Flexible time off alongside 9 Paid Holidays.