Utilization Management Nurse, RN

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

📋 Description

• Collaborate with external agencies and representatives engaged in utilization management, including health plans, medical providers, vendors, and CMS.

• Conduct both prospective and retrospective utilization reviews for elective and urgent hospital admissions, as well as outpatient services listed under Prior Authorization.

• Generate comprehensive and timely reports for members, providers, and health plans.

• Assist medical directors with benefit interpretation, gathering medical necessity information, and investigating issues.

• Engage in case discussions as necessary.

• Oversee incoming authorization requests and specialist referrals in collaboration with physicians, healthcare providers, health plan representatives, care management staff, and UM Coordinators.

• Utilize nationally recognized guidelines to assess medical necessity.

• Evaluate authorization requests and medical documentation for medical necessity and appropriateness based on health plan criteria, as well as BTP, CMS, CDC, NCQA, and DMHC standards.

• Review cases against DOFR, Health Plan Ancillary Grids, and BTP Ancillary lists to ensure the selection of appropriate vendors.

• Draft denial letter language in compliance with ICE and health plan specifications.

• Ensure accurate maintenance of case data in Tapestry, including ICD-10, CPT, and HCPC codes.

• Participate in the annual inter-rater review to assess nursing decision-making consistency.

• Provide support to Inpatient Care Management, Network Management, Claims, Customer Service, Quality Improvement, and Physician Services staff concerning benefit interpretation, UM policies and procedures, and guideline application.

⛳️ Requirements

• RN-Registered Nurse licensure in California is required.

• A minimum of 2 years of recent relevant experience.

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

• Prior experience in MSO is preferred.

• Recent experience with MCG or InterQual is highly desired.

• Experience with ICD-9, CPT, and HCPCS codes is preferred.

• External candidates must successfully pass a background check and drug screening.

• A commitment to patient-centered care and the promotion of health and wellness is essential.

🏝️ Benefits

• Comprehensive medical, vision, and dental coverage.

• 401k savings plan with company matching contributions.

• Flexible time off policy.

• 9 Paid Holidays.

• Eligibility for an annual bonus program.

• Competitive compensation package.

• Background check and drug screening required for external hires.