Impactful Denials Review Nurse — Utilization Management

UCLA Outpatient Clinics; Los Angeles (CA); Hybrid; USD 66,000 - 131,000; Full time

Job summary

UCLA Outpatient Clinics in Los Angeles is seeking a UM Denial Nurse Reviewer to apply clinical knowledge, policies, and regulatory guidelines to review adverse determinations and ensure accurate, timely notifications.

The role involves reviewing denials for proper documentation and criteria, providing clinical guidance, and collaborating with denial coordinators, prior authorization teams, and medical leadership to support appropriate denial determinations.

Qualifications

• Review and process denials for appropriate clinical documentation, clinical criteria/guidelines, benefit policies, and regulatory compliance.
• Apply clinical knowledge and the appropriate clinical review hierarchy when evaluating denial cases and written notifications.
• Collaborate with Denial Coordinators, Prior Authorization teams, Medical Directors, and department leadership to clarify cases and support appropriate denial determinations.
• Monitor denial processing and turnaround times to ensure regulatory standards and guidelines are met.
• Review denial letters for clear, understandable language and compliance with applicable requirements.
• Identify trends in denial types and outcomes and support process improvement initiatives.
• Develop and analyze denial activity and outcome reports to identify opportunities for improvement.

Responsibilities

• Review and process denials for appropriate clinical documentation, clinical criteria/guidelines, benefit policies, and regulatory compliance.
• Apply clinical knowledge and the appropriate clinical review hierarchy when evaluating denial cases and written notifications.
• Collaborate with Denial Coordinators, Prior Authorization teams, Medical Directors, and department leadership to clarify cases and support appropriate denial determinations.
• Monitor denial processing and turnaround times to ensure regulatory standards and guidelines are met.
• Review denial letters for clear, understandable language and compliance with applicable requirements.
• Identify trends in denial types and outcomes and support process improvement initiatives.
• Develop and analyze denial activity and outcome reports to identify opportunities for improvement.

Job description

UCLA Outpatient Clinics in Los Angeles is seeking a UM Denial Nurse Reviewer to apply clinical knowledge, policies, and regulatory guidelines to review adverse determinations and ensure accurate, timely notifications.

The role involves reviewing denials for proper documentation and criteria, providing clinical guidance, and collaborating with denial coordinators, prior authorization teams, and medical leadership to support appropriate denial determinations.