Denial Review Nurse

2 weeks ago

Monterey Park, United States Astrana Health Full time

Job Title: Denial Review Nurse 
Department: Health Services - Denials 
 
About the Role:

We are currently seeking a highly motivated Denial Review Nurse. This role will report to a Manager - Denials and enable us to continue to scale in the healthcare industry. 
 

 What You'll Do:  

  • Responsible for managing all deferrals and or denials by conducting a comprehensive review of clinical documentation, clinical criteria/guideline, policy, and or EOC/benefit policy 
  • Apply clinical knowledge when processing all deferrals and or denials, supported by clinical criteria, including but not limited to DMHC, DHCS, CMS, Health Plan, Milliman Care Guidelines (“MCG”), and UpToDate 
  • Comply with company and department policies and procedures to ensure timely and accurate processing of all deferrals and or denials 
  • Review and process daily assigned deferrals or denials (denial, modify, carve out, etc.) with a minimal of 30-40 letters per day with accuracy and quality 
  • Perform other duties, projects and actions as assigned 

Qualifications:   

  • Possession of an active, unrestricted, and current California Registered Nurse (RN) or Licensed Vocational Nurse (LVN) license
  • Proficient in Microsoft Office applications 
  • Strong written and oral communication skills 

You're a great fit for this role if:  

  • Exceptional follow-through abilities to track all outstanding tasks and coordinate with assigned owners to ensure tasks are completed timely 
  • Strong organizational skills, detail oriented, and sound decision-making skills required 
  • Ability to manage multiple projects of varying complexity, priority levels and deadlines
  • Utilization management experience with a Health Plan or MSO
  • Proficient knowledge of Health Plan, DMHC, DHCS, CMS, HIPPA and NCQA requirements 

Who We Are:  

Astrana Health (NASDAQ: ASTH) is a physician-centric, technology-powered healthcare management company. We are building and operating a novel, integrated, value-based healthcare delivery platform to empower our physicians to provide the highest quality of end-to-end care for their patients in a cost-effective manner. Our mission is to combine our clinical experience, best-in-class delivery network, and technological expertise in order to improve patient outcomes, increase access to healthcare, and make the US healthcare system more efficient. 

Our platform currently empowers over 12,000 physicians to provide care for over 1.3 million patients nationwide. Our rapid growth and unique position at the intersection of all major healthcare stakeholders (payer, provider, and patient) gives us an unparalleled opportunity to combine clinical and technological expertise in order to improve patient outcomes, increase access to quality healthcare, and reduce the waste in the US healthcare system.
 

Our Values:  

  • Put Patients First 
  • Empower Entrepreneurial Provider and Care Teams 
  • Operate with Integrity & Excellence 
  • Be Innovative 
  • Work As One Team 

Environmental Job Requirements and Working Conditions: 

  • This is a hybrid position. The position will be fully in-office for 3 month probationary period. After successful completion of probationary period, position will transition to 2 days in-office and 3 days at home. The position is located at 1600 Corporate Center Dr, Monterey Park, CA 91754. 
  • This position will typically work Monday - Friday from 8:30 am to 5:00 pm. There is ample opportunity for overtime pay. We also require weekend and holiday coverage if there is business need. 
  • The target pay range for this role is $30.00 - $45.00 per hour. This salary range represents our national target range for this role.

Astrana Health is proud to be an Equal Employment Opportunity and Affirmative Action employer. We do not discriminate based upon race, religion, color, national origin, gender (including pregnancy, childbirth, or related medical conditions), sexual orientation, gender identity, gender expression, age, status as a protected veteran, status as an individual with a disability, or other applicable legally protected characteristics. All employment is decided on the basis of qualifications, merit, and business need. If you require assistance in applying for open positions due to a disability, please email us at humanresourcesdept@networkmedicalmanagement.com to request an accommodation. 
 

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.

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