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 Pre-Service (Outpatient) Review Nurse is responsible for managing inpatient & outpatient utilization by 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 clinical documentation, applying clinical criteria and guidelines.
• Review authorization requests for medical necessity with best clinical judgement, ensuring adherence to regulatory and health plan criteria, policies, and Evidence of Coverage (EOC).
• Write denials using the Flesch-Kincade grading scale to ensure 8th grade reading level language to be provided for members.
• Ensure timely and accurate processing of all authorization requests in compliance with company and departmental policies and procedures.
• Review and process denials, modifications, and carve-outs according to established procedures and clinical criteria.
• Use clinical expertise to apply relevant clinical guidelines to ensure that medical decisions align with best practices and regulations.
• Collaborate with healthcare providers, the Utilization Management (UM) team, and compliance departments to ensure clear communication and appropriate utilization of healthcare services.
• Ensure proper case review with proper documentation, treatment evaluation, adherence to evidence-based practices, and completeness of request.
• Maintain regulatory compliance and turnaround time standards per CMS.
• Facilitates interdisciplinary communication between specialists as needed and interdepartmental participation.
• Communicates with IPA/MSO in health plan goals and ensuring joint operation expectations are met.
• Identifies and discusses complex cases with potential for high utilizers with Medical Director and Manager of Utilization Management as needed.
• Coordinate with the Appeals team to support the completion of appeal process as needed.
• 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, Medicare, Apollo Managed Care, 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 Insurance
• Health Insurance
• Life Insurance
• Vision Insurance
• Paid Time Off
• Catered lunches