UM Outpatient Review Nurse

All Care To You; Oregon; Hybrid; USD 90,000 - 120,000; Full time

Benefits offered by this job

Fully employer-paid medical, vision, &

Job summary

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

Qualifications

• 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.

Responsibilities

• 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.

Skills

Clinical decision making

Communication skills

Time management

Attention to detail

Confidentiality

Education

RN license (CA & TX multi-state)

CM/UM training or certification

Tools

Outlook

Microsoft Teams

Zoom

Microsoft Office

Adobe

Job description

About UsAll Care To You is a Management Service Organization providing our clients with healthcare administrative support. We provide services to Independent Physician Associations, TPAs, and Fiscal Intermediary clients. ACTY is a modern growing company which encourages diverse perspectives. We celebrate curiosity, initiative, drive and a passion for making a difference. We support a culture focused on teamwork, support, and inclusion. Our company is fully remote and offers a flexible work environment as well as schedules.

Benefits

• 100% employer paid medical, vision, dental, and life coverage for our employees
• Additional employee paid coverage options available
• Paid holidays
• Birthday off
• Unlimited PTO
• 401k plan

Job purpose

The position of UM Outpatient Review Nurse reports to the Director, Case Management. The position of UM Outpatient Review Nurse is part of the Case Management team and is responsible for clinical, quality, and patient outcomes. This position is expected to implement the effectiveness and best practices of Utilization Review and will provide high quality medical review by appropriately applying the State, Federal, health plan and clinical guidelines used to determine medical necessity.

Duties and responsibilities

• Review authorization requests for medical necessity, determines which requests need Medical Director review, obtains sufficient medical documentation for an informed consent
• Process all requests within established time frames
• Documents all steps of process in authorization system in the authorization notes
• Utilizes CMS and Health Plan Hierarchy criteria
• Clinical documentation, specific criteria, and record attachment for referral prior to sending to the Medical Director for review
• Retrospective review of services to determine medical necessity
• Refer cases to the Medical Director for review of requests that may not meet medical necessity criteria
• Process denials within established timeframes
• Writes denial letters to meet CMS and Health Plan requirements
• Work closely with other MSO team members as necessity requires
• Applies the appropriate clinical criteria/guideline, policy, EOC/benefit policy and clinical judgment to render coverage determination/recommendation for the review process
• Review member's utilization and claim history when processing a referral
• Maintain quality reviews while meeting the established TATs for Urgent, Routines and Retro requests
• Maintains Interrater Reliability Rate at least 95% or above
• Daily production standard is a minimum of 50-90 referrals/day depending on complexity with accuracy & quality
• Makes approval determinations when request meets appropriateness, medical necessity and benefit criteria
• Utilizes clinical experience and skills in a collaborative process to assess, plan, implement, coordinate, monitor and evaluate options to facilitate appropriate healthcare services that meet criteria and can be authorized by a nurse level reviewer
• Act as clinical resource to all departments
• Communicates with health plans, providers, members and other parties to facilitate member care treatment plans
• Participating in team training
• Comply with UM policies and procedures
• Annual review of UM policies
• Attend to provider and interdepartmental calls in accordance with exceptional customer service
• Ability to keep high level of confidence and discretion when dealing with sensitive matters relating to providers, and members. Always maintains strict confidentiality
• Other duties as needed

Qualifications

• A valid CA and Texas/Multi State Registered Nurse license or Licensed Vocational Nurse
• CM and/or UM training and/or certification. Knowledge of CM standards, UM standards, Clinical Standards of Care, NCQA requirements, CMS guidelines, Milliman guidelines, and InterQual guidelines. Medi-Cal, Commercial and Medicare contracts and benefit interpretation is preferred
• Five years+ clinical experience
• Prefer of two (2) years+ experience in an HMO/IPA/Managed care setting is preferred and recommended
• Must be available to work weekends and holidays, as business needs require
• Ability to work independently with minimal supervision, exercising judgment and initiative
• Ability to manage multiple tasks with effective prioritization
• Proficiency using Outlook, Microsoft Teams, Zoom, Microsoft Office (including Word and Excel) and Adobe
• Must be available to work weekends and holidays, as business needs require
• Detail oriented and highly organized
• Strong ability to multi-task, project management, and work in a fast-paced environment
• Strong ability in problem-solving
• Ability to manage self-manage, strong time management skills
• Ability to work in an extremely confidential environment
• Strong written and verbal communication skills

Education and Additional Requirements

• Holds Current Unrestricted CA and Texas/Multi State RN or LVN license