UM Review Nurse

Astrana Health; United States; Remote; USD 47,000 - 65,000; Full time

Job summary

Astrana Health is seeking a CA-licensed Utilization Review Nurse to support our Health Services Department. You will review outpatient services for medical necessity and approve or deny based on plan criteria, applying clinical judgement.

This is a remote position for CA-licensed nurses with residency in California. Candidates require at least one year of outpatient utilization management experience in a fast-paced setting and must be available for a 5-shift weekly schedule, including some

Qualifications

• Active and unrestricted CA RN or LVN license.
• Experience in outpatient utilization management or health plans.
• Proficient with Microsoft Office applications.

Responsibilities

• Complete prior authorization/retrospective review of outpatient services.
• Refer cases to Medical Directors as needed.
• Maintain knowledge of state and federal regulations and accreditation standards.
• Comply with internal policies and procedures.
• Perform other duties as requested.

Skills

Interpersonal skills

Collaboration

Staff training

Utilization review

Microsoft Word/Excel/Outlook

Education

CA RN or LVN license

Tools

Word

Excel

Outlook

Job 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 or RN license in California,
• Experience with Microsoft applications such as Word, Excel, and Outlook

You’ll be Great for this Role If:

• 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

Environmental 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 Affirmitive 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. If you require assistance in applying for open positions due to a disability, please email us at [e-mail] 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.