Utilization Management Nurse, RN

Altais Health Solutions; Oakland (CA); On-site; USD 12,330,000 - 14,795,000; Full time

Benefits offered by this job

Medical, vision, and dental coverage

401k with company match

Flexible time off & 9 paid holidays

Job summary

Altais Health Solutions is seeking a Utilization Management RN to drive efficient authorization processes and advocate with health plans. You will review cases for medical necessity, interface with physicians and health plans, and support care management teams in delivering patient-centered outcomes.

The role requires California RN licensure, knowledge of reimbursement models, and experience with UM processes. A strong collaboration mindset and attention to detail are essential.

Qualifications

• RN-Registered Nurse licensure in California is required.
• Awareness of healthcare reimbursement systems (HMO, PPO, PPS, CMA, value-based models) preferred.
• Prior MSO experience preferred.
• 2 years of recent relevant experience.
• MCG or InterQual experience highly desirable.
• Experience with ICD-9, CPT and HCPCS codes preferred.

Responsibilities

• Perform Utilization Review activities prospectively or post-service for elective/urgent hospital admissions and outpatient services, with reports to members, providers and health plans.
• Interface with external agencies and representatives in the utilization management process.
• Assist medical directors with benefit interpretation and obtain additional information for medical necessity.
• Collaborate with UM Coordinators to provide medical management for authorization requests and referrals.
• Review cases for medical necessity and appropriateness against plan criteria and industry guidelines.

Skills

California RN licensure

Healthcare reimbursement systems

MSO experience

MCG/InterQual experience

ICD-9/CPT/HCPCS codes

2 years relevant experience

Job description

About Altais:At Altais, we’re on a mission to improve the healthcare experience for everyone—starting with the people who deliver it. We believe physicians should spend more time with patients and less time on administrative tasks. Through smarter technology, purpose-built tools, and a team-based model of care, we help doctors do what they do best: care for people.Altais includes a network of physician-led organizations across California, including Brown & Toland Physicians, Altais Medical Group Riverside, and Family Care Specialists. Together, we’re building a stronger, more connected healthcare system.About the RoleAre you looking to join a fast-growing, dynamic team?We’re a collaborative, purpose-driven group that’s passionate about transforming healthcare from the inside out. At Altais, we support one another, adapt quickly, and work with integrity as we build a better experience for physicians and their patients.As a Utilization Management RN, you'll work closely with our Ambulatory and Concurrent Care, Network Management, Quality Improvement, and Practice Success teams. Your responsibilities include driving efficient authorization processes, navigating insurance requirements with precision and advocacy. We seek individuals with a strong commitment to patient-centered care and a passion for promoting health and wellness.You will focus on:Interface with external agencies and representatives relative to the utilization management process, including health plans, medical providers, vendors and CMS.Perform Utilization Review activities prospectively or post-service (retrospective) for elective/urgent hospital admissions and outpatient services as specified on the Prior Authorization List with complete and timely reports to members, providers and health plans as requested.Assist medical directors with benefit interpretation, obtain additional medical necessity information and research issues. Be available for case discussion as needed.Works closely with physicians, other healthcare and service providers, health plan representatives, care management staff and partners with UM Coordinators to provide medical management for incoming authorization requests and specialist referrals using nationally recognized guidelines to determine medical necessity.Review the authorization request and medical information provided by the requesting provider for medical necessity and appropriateness, comparing information to current medical care criteria by health plan and as specified by BTP, CMS, CDC, NCQA and DMHC requirements.Review all cases against the division of financial responsibility (DOFR), Health Plan Ancillary Grids and BTP Ancillary lists to ensure appropriate vendors are utilized for payment of services.Formulate appropriate denial letter language in accordance with Industry Collaboration effort (ICE)and health plan requirementsEnsure accuracy of case data in Tapestry including ICD-10, CPT and HCPC codesParticipate in the annual inter-rater review to evaluate consistency of decision making with in the nursing staff Support Inpatient Care Management, Network Management, Claims, Customer Service, Quality Improvement and Physician Services staff by offering benefit interpretation, understanding of UM policies and procedures and the application of guidelines in the process of decision making.The Skills, Experience & Education You BringRN-Registered Nurse of California Licensure required.Awareness of healthcare reimbursement systems: HMO, PPO, PPS, CMA, all value-based reimbursement models, and alternative payment systems preferred.Prior MSO experience preferred.2 years recent relevant experience.Recent MCG or InterQual experience highly desired.Experience with ICD-9, CPT and HCPCS codes preferredThe Base Salary for this position is $44.63 - $53.55/hrIn addition, we provide a competitive compensation package that recognizes your experience, credentials, and education alongside a robust benefits program to meet your needs.Excellent medical, vision, and dental coverage401k savings plan with a company matchFlexible time off and 9 Paid HolidaysYou Share Our Mission & Values:CompassionWe act with empathy and a deep respect for the challenges faced by physicians and their patients. Our work is driven by a genuine commitment to improving lives and ensuring that care is delivered with dignity, understanding, and humanity.CommunityWe foster a culture of collaboration-with physicians, patients across the healthcare ecosystem, and among our teams. By building strong, trusted relationships, we create a unified community focused on advancing patient care and physician well-being.LeadershipWe lead with integrity and vision, setting the standard for excellence in physician support and healthcare innovation. Through collaboration and expertise, we empower others to lead, drive change, and shape the future of care.ExcellenceWe are relentlessly focused, results-driven, and accountable for delivering measurable value to physicians and the patients they serve. Our high standards reflect our commitment to excellence, operational discipline, and continuous improvement.AgilityWe embrace change as a constant and respond swiftly to the evolving needs of the healthcare industry. With flexibility and forward-thinking, we adapt, innovate, and act decisively to keep physicians at the forefront.Altais values the contribution each Team Member brings to our organization. Final determination of a successful candidate’s starting pay will vary based on several factors, including, but not limited to education and experience within the job or the industry. The pay scale listed for this position is generally for candidates that meet the specified qualifications and requirements listed on this job description. Additional pay may be determined for those candidates that exceed these specified qualifications and requirements. We provide a competitive compensation package that recognizes your experience, credentials, and education alongside a robust benefits program to meet your needs.The anticipated pay range for this role is listed in our salary posting for transparency but may vary based on factors including the candidate’s qualifications, skills, and experience. This position will also be eligible to participate in our annual bonus program.Altais and its subsidiaries and affiliates are committed to protecting the privacy and security of the personal information you provide to us. Please refer to our ‘CPRA Privacy Notice for California Employees and Applicants’ to learn how we collect and process your personal information when you apply for a role with us.External hires must pass a background check/drug screen. Qualified applicants with arrest records and/or conviction records will be considered for employment in a manner consistent with Federal, State and local laws, including but not limited to the San Francisco Fair Chance Ordinance. All qualified applicants will receive consideration for employment without regards to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran status or disability status and any other classification protected by Federal, State and local laws.