UM Review Nurse

Astrana Health Management; Monterey Park, Northern (CA, KY); Hybrid; USD 47,000 - 65,000; Full time

Job summary

Astrana Health Management in California is seeking a CA-licensed Utilization Review Nurse to support our Health Services Department. You will review outpatient services for medical necessity according to plan criteria.

This is a remote role for CA-licensed nurses; candidates must reside in California. At least 1 year of outpatient UM experience is required, with compensation in the $34-$47 per hour range depending on experience and location.

Qualifications

• Active and unrestricted LVN license in CA.
• At least 1 year of outpatient UM experience.
• Experience with Microsoft applications such as Word, Excel, and Outlook.

Responsibilities

• Complete prior authorization/retrospective review of elective inpatient admissions, outpatient procedures, post-homecare services, and durable medical equipment.
• Refer cases to Medical Directors as needed/appropriate.
• Maintain knowledge of state and federal regulations and accreditation standards.
• Comply with internal policies and procedures.
• Perform any other job duties as requested.

Skills

Outpatient UM experience

Microsoft Word

Microsoft Excel

Microsoft Outlook

Education

Active California LVN license

Job description

Utilization Management Review Nurse

Department: HS - UM

Employment Type: Full Time

Location: 1600 Corporate Center Dr., Monterey Park, CA 91754

Reporting To: Phillip Vasquez

Compensation: $34.00 - $42.00 / hour

Description

Astrana Health is looking for a CA-licensed Utilization Review Nurse to assist our Health Services Department. In this position, you will utilize your clinical judgement to approve or deny outpatient medical services for patients based on Medical Necessity Criteria, respective to various Health Plans.

This is a remote position for CA-licensed nurses. Candidates must live in California.

We are seeking nurses with at least one year of outpatient Utilization Management experience in a fast-paced setting.

Our Values:

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

What You’ll Do

• Complete prior authorization/retrospective review of elective inpatient admissions, outpatient procedures, post-homecare services, and durable medical equipment
• Refer cases to Medical Directors as needed/appropriate
• Maintain knowledge of state and federal regulations and accreditation standards
• Comply with internal policies and procedures
• Perform any other job duties as requested

Qualifications

• Active and unrestricted LVN license in CA.
• At least 1 years of outpatient UM experience
• Experience with Microsoft applications such as Word, Excel, and Outlook

You’ll be Great for this Role If:

• At least two (2) years of health plan, IPA or MSO experience
• Strong interpersonal skills
• Ability to collaborate with co-workers, senior leadership, and other management
• Experience educating and training staff

Enviornmental Job Requirements and Working Conditions

• This is a remote position. Our office is located at 1600 Corporate Center Drive in Monterey Park, CA. Candidates who live within a 30 mile radius of the office may be expected to work hybrid.
• Typical business hours are Monday - Friday from 8:30 AM to 5 PM, however, this position requires open availability between 8 AM - 8 PM PST, M-Su. Your schedule will be compromised of 5 shifts per week. Nurses rotate weekend and holiday coverage. Overtime is required in this position.
• The national target pay range for this role is $34.00 - $47.00 per hour. Actual compensation will be based on job level, geographic location (current or future), experience, and other job-related factors.

Astrana Health is proud to be an Equal Employment Opportunity and Affimative Action employer. We do not discriminate based on 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 based on qualifications, merit, and business need.

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.