Utilization Review Denial Nurse — Hybrid/Remote

UCLA Health; Los Angeles (CA); Hybrid; USD 66,000 - 131,000; Full time

Job summary

UCLA Health in Los Angeles hires a Denial Nurse Reviewer to support high-quality, cost-effective care by applying clinical knowledge, policies, and regulatory guidelines to review and process adverse organization determinations.

Responsibilities include reviewing denials for proper documentation, applying review hierarchy, collaborating with Denial Coordinators, Prior Authorization teams, Medical Directors, and leadership to support accurate denial determinations, and monitoring turnaround times

Qualifications

• Current CA LVN licensure required.
• Two or more years of utilization review/utilization management experience in an HMO, MSO, IPA, or health plan environment.
• Previous clinical experience.
• Experience drafting and issuing compliant adverse organization determinations.
• In-depth knowledge of health plan, DMHC, CMS, HIPPA, and NCQA requirements.
• Expertise in abstracting and interpreting medical information from patient records.
• Thorough understanding of the Hierarchy of Clinical Criteria.
• Experience with Flesch-Kincaid readability scoring.
• Knowledge of the appeals process.
• Experience with audit preparation.
• Basic computer skills.

Responsibilities

• Review and process denials for appropriate clinical documentation, clinical criteria/guidelines, benefit policies, and regulatory compliance.
• Apply clinical knowledge and the appropriate clinical review hierarchy when evaluating denial cases and written notifications.
• Collaborate with Denial Coordinators, Prior Authorization teams, Medical Directors, and department leadership to clarify cases and support appropriate denial determinations.
• Monitor denial processing and turnaround times to ensure regulatory standards and guidelines are met.
• Review denial letters for clear, understandable language and compliance with applicable requirements.
• Identify trends in denial types and outcomes and support process improvement initiatives.
• Develop and analyze denial activity and outcome reports to identify opportunities for improvement.

Skills

Strong communication

Analytical

Problem-solving

Organizational skills

Prioritizing

Education

CA LVN licensure

Tools

Basic computer skills

Job description

UCLA Health in Los Angeles hires a Denial Nurse Reviewer to support high-quality, cost-effective care by applying clinical knowledge, policies, and regulatory guidelines to review and process adverse organization determinations.

Responsibilities include reviewing denials for proper documentation, applying review hierarchy, collaborating with Denial Coordinators, Prior Authorization teams, Medical Directors, and leadership to support accurate denial determinations, and monitoring turnaround times