Remote Utilization Review Nurse - Outpatient Care

All Care To You; Oregon; Híbrido; USD 90.000 - 120.000; Tempo integral

Benefícios oferecidos por esta vaga

Fully employer-paid medical, vision, &

Resumo da vaga

All Care To You is hiring a UM Outpatient Review Nurse to join the Case Management team. You will perform clinical reviews to determine medical necessity using state and CMS guidelines, working remotely with flexibility and a focus on high quality outcomes.

The position requires nursing licensure in CA/Texas multi-state and CM/UM training, with experience in managed care settings. Responsibilities include evaluating authorization requests, coordinating with Medical Directors, and ensuring timely

Qualificações

• Valid CA and Texas/Multi State RN or LVN license.
• CM/UM training or certification; knowledge of CM/UM standards and guidelines.
• Minimum five years clinical experience.
• Experience in HMO/IPA or managed care settings preferred.
• Willingness to work weekends and holidays.

Responsabilidades

• Review authorization requests for medical necessity and determine need for Medical Director review.
• Process requests within established timeframes and document steps in authorization system.
• Apply CMS and Health Plan criteria to determine coverage decisions.
• Retrospective review of services to assess medical necessity.
• Communicate with plans, providers, and members to support care plans.
• Maintain high quality reviews and meet turnaround times for urgent and routine referrals.

Conhecimentos

Clinical decision making

Communication skills

Time management

Attention to detail

Confidentiality

Formação

RN license (CA & TX multi-state)

CM/UM training or certification

Ferramentas

Outlook

Microsoft Teams

Zoom

Microsoft Office

Adobe

Descrição da vaga

All Care To You is hiring a UM Outpatient Review Nurse to join the Case Management team. You will perform clinical reviews to determine medical necessity using state and CMS guidelines, working remotely with flexibility and a focus on high quality outcomes.

The position requires nursing licensure in CA/Texas multi-state and CM/UM training, with experience in managed care settings. Responsibilities include evaluating authorization requests, coordinating with Medical Directors, and ensuring timely