Active and unrestricted LVN or RN license in California
At least one year of outpatient Utilization Management experience
Proficient in Microsoft Word, Excel, and Outlook
Two years of health plan, IPA, or MSO experience preferred
Strong interpersonal skills
Responsibilities
Complete prior authorization and retrospective reviews for various medical services
Refer cases to Medical Directors as necessary
Maintain knowledge of relevant state and federal regulations
Ensure compliance with internal policies and procedures
Perform additional duties as assigned
Benefits
Remote work opportunity for California-licensed nurses
Flexible scheduling with open availability required
Rotating weekend and holiday coverage
Overtime opportunities available
Collaborative work environment with senior leadership
Full Job Description
UM Review Nurse
Department: HS - UM
Employment Type: Full Time
Location: 1600 Corporate Center Dr., Monterey Park, CA 91754
Reporting To: Phillip Vasquez
Compensation: $34.00 - $47.00 / hour
Description
In this position, you will utilize your clinical judgement to approve or deny outpatient medical services for patients based on Medical Necessity Criteria, respective to various Health Plans.
This is a remote position for CA-licensed nurses. Candidates must live in California.
We are seeking nurses with at least one year of outpatient Utilization Management experience in a fast-paced setting.
What You'll Do
Complete prior authorization/retrospective review of elective inpatient admissions, outpatient procedures, post-homecare services, and durable medical equipment
Refer cases to Medical Directors as needed/appropriate
Maintain knowledge of state and federal regulations and accreditation standards
Comply with internal policies and procedures
Perform any other job duties as requested
Qualifications
Active and unrestricted LVN or RN license in California,
Experience with Microsoft applications such as Word, Excel, and Outlook
You'll be Great for this Role If:
Two (2) years of health plan, IPA or MSO experience
Strong interpersonal skills
Ability to collaborate with co-workers, senior leadership, and other management
Experience educating and training staff
Environmental Job Requirements and Working Conditions
This is a remote position. Our office is located at 1600 Corporate Center Drive in Monterey Park, CA. Candidates who live within a 30 mile radius of the office may be expected to work hybrid.
Typical business hours are Monday - Friday from 8:30 AM to 5 PM, however, this position requires open availability between 8 AM - 8 PM PST, M-Su. Your schedule will be compromised of 5 shifts per week. Nurses rotate weekend and holiday coverage. Overtime is required in this position.
The national target pay range for this role is $34.00 - $47.00 per hour. Actual compensation will be based on job level, geographic location (current or future), experience, and other job-related factors.
Additional Information: The job description does not constitute an employment agreement between the employer and employee and is subject to change by the employer as the needs of the employer and requirements of the job change.
