Utilization Management Review Nurse

About Us:Astiva Health, Inc., located in Orange, CA is a premier healthcare provider specializing in Medicare and HMO services. With a focus on delivering comprehensive care tailored to the needs of our diverse community, we prioritize accessibility, affordability, and quality in all aspects of our services. Join us in our mission to transform healthcare delivery and make a meaningful difference in the lives of our members.SUMMARY: The Utilization Management Inpatient Review Nurse is responsible for managing inpatient conducting thorough reviews of clinical documentation and applying clinical knowledge in accordance with relevant Care Guidelines and CMS regulations. This role ensures that all authorizations, deferrals, and denials are processed efficiently, accurately, and in compliance with company policies and regulatory standards. The nurse also issues timely and accurate denial, deferral, or authorization letters, manages clinical & concurrent review processes, and supports compliance with health plan guidelines.ESSENTIAL DUTIES AND RESPONSIBILITIES include the following:Manage all authorizations, deferrals, and denials by conducting comprehensive reviews of inpatient hospital stays, applying clinical criteria and guidelines.Review inpatient hospital stay requests for medical necessity, ensuring adherence to regulatory and health plan criteria, policies, and Evidence of Coverage (EOC).Ensure timely and accurate processing of all admissions and identifies appropriate level of care and continued stay based on acceptable evidence-based guidelines use by health plan.Generates referrals to contracted ancillary service providers and community agencies with the agreement of the patient’s primary care physician.Use clinical expertise to apply relevant clinical guidelines to ensure that medical decisions align with best practices and regulations.Performs follow-up reviews and evaluations of patients in the ambulatory care or lower level of care setting.Communicate and collaborates with IPA/MSO as necessary for effective management of the membersIssue NOMNCs and subsequent DENCs through QIO Appeals as necessary with best clinical judgement and guidelines.Arranges and participates in multidisciplinary patient care conferences or rounds.Monitors, documents, and reports pertinent clinical criteria as established per UM policy and procedure.Reports any progress of all open cases to the Medical Director and Manager of Utilization Management.Identifies members who may need complex or chronic case management post discharge and handoff to appropriate staff for ambulatory follow-up, as necessary.Effectively communicates with patients, their families/support systems and collaborates with physicians and ancillary service providers to coordinate care activities.When time permits, all staff are expected to assist others within the department within the department to facilitate workflow and the referral process.Perform additional duties, projects, and actions assigned to support department goals and operational needs.Regular and consistent attendance.EDUCATION and/or EXPERIENCE:Licensed Vocational Nurse (LVN) or Registered Nurse (RN) with an active, unrestricted license in the state of practice.Minimum of 3 years of clinical nursing experience, with a focus on Utilization Management or managed care preferred.Familiarity with Milliman Care Guidelines (MCG), InterQual, Apollo Managed Care, Medicare, and CMS regulations.Utilization management experience with a Health Plan or Management Services Organization (MSO).Proficient in applying clinical knowledge to support medical necessity decisions based on health plan policies, benefit guidelines, and regulatory criteria.Excellent organizational skills and the ability to process a high volume of authorization requests with accuracy and attention to detail.Strong communication skills, both verbal and written, especially in creating clear and compliant deferral and denial letters.Ability to collaborate with cross-functional teams, including providers and internal UM teams.Exceptional follow-through abilities to track all outstanding tasks and coordinate with assigned owners to ensure tasks are completed in a timely manner.Strong organizational skills, attention to detail, and sound decision-making skills required.Ability to manage multiple projects of varying complexity, priority levels, and deadlines.Proficient knowledge of Health Plan, DMHC, DHCS, CMS, HIPAA, and NCQA requirements.BENEFITS:401(k)Dental InsuranceHealth InsuranceLife InsuranceVision InsurancePaid Time OffCatered lunches