Utilization Management Nurse Reviewer (Inpatient/Outpatient)

Astiva Health, Inc; California; Sur place; USD 70 000 - 90 000; Plein temps

Avantages offerts par ce poste

401(k)

Health Insurance

Life Insurance

Vision Insurance

Paid Time Off

Résumé du poste

Astiva Health, Inc. in Orange, CA seeks an experienced Utilization Management Authorization Review Nurse to manage inpatient and outpatient utilization. You will review clinical documentation, apply CMS and health plan guidelines, and issue denials, deferrals, or authorizations.

The role requires an active LVN license, 3+ years in clinical nursing with UM experience, and familiarity with MCG/InterQual. You will collaborate with UM teams and providers to ensure compliant utilization and timely

Qualifications

• Licensed Vocational Nurse (LVN) with active, unrestricted license in the state of practice.
• Bachelor’s Degree in Nursing preferred.
• Minimum of 3 years of clinical nursing experience, UM or managed care preferred.
• Familiarity with MCG, InterQual, Medicare, Medicaid, and CMS regulations.
• Utilization management experience with a Health Plan or MSO.
• Strong knowledge of CMS guidelines and benefit policies.

Responsabilités

• Manage authorizations, deferrals, and denials through clinical documentation reviews.
• Assess medical necessity per CMS, health plan criteria, and EOC.
• Apply clinical knowledge to deferrals/denials per CMS, DMHC, DHCS guidelines.
• Ensure timely processing of authorization requests per policies.
• Coordinate with Appeals to support denial letters and determinations.
• Collaborate with UM team and providers to ensure compliant utilization.

Connaissances

Utilization Management

Clinical documentation review

Regulatory compliance

Communication skills

Formation

Licensed Vocational Nurse (LVN) license

Bachelor’s Degree in Nursing preferred

Outils

Milliman Care Guidelines (MCG)

InterQual

CMS regulations

HIPAA knowledge

Description du poste

Astiva Health, Inc. in Orange, CA seeks an experienced Utilization Management Authorization Review Nurse to manage inpatient and outpatient utilization. You will review clinical documentation, apply CMS and health plan guidelines, and issue denials, deferrals, or authorizations.

The role requires an active LVN license, 3+ years in clinical nursing with UM experience, and familiarity with MCG/InterQual. You will collaborate with UM teams and providers to ensure compliant utilization and timely