Utilization Review Nurse - Remote

Astrana Health; California (MO); Remote; USD 41,328 - 46,838; Full time

Job summary

A healthcare services company is seeking an experienced Utilization Review Nurse to work remotely. The ideal candidate must hold an active LVN license in California and have experience in outpatient utilization management. Responsibilities include approving or denying medical services based on established criteria. Competitive hourly compensation ranges from $30.00 to $34.00. Join our dedicated team committed to putting patients first.

Qualifications

• Experience in outpatient UM; case management experience alone is not sufficient.
• Strong collaborative skills with colleagues and leadership.

Responsibilities

• Review outpatient medical services for medical necessity.
• Complete prior authorization and retrospective review.
• Maintain state and federal regulation knowledge.

Skills

Outpatient Utilization Management

Interpersonal Skills

Experience with Microsoft Word

Experience with Microsoft Excel

Experience with Microsoft Outlook

Education

Active LVN license in California

Job description

Overview

Utilization Review Nurse - Remote at Astrana Health

Location: 600 City Parkway West 10th Floor, Orange, CA 92868

Compensation: $30.00 - $34.00 / hour

Department: HS - UM

This is a fully remote position.

Description

Astrana Health is looking for an experienced 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 position will typically work M-F 8 AM - 5 PM. This is a fully remote position.

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 California
• MUST have experience in outpatient UM. Candidates with only case management experience are not a fit.
• Experience with Microsoft applications such as Word, Excel, and Outlook
• Experience working with authorizations, referrals, or health insurance required

You’ll be Great for this Role If

• Two (2) years of health plan, UM, 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. Candidates must have an active and unrestricted CA license.
• This position will typically work Monday - Friday from 8:00 am to 5:00 pm PST. There may be up to 1 hour of voluntary OT per day.
• The target pay range for this role is $30.00 - $34.00 per hour for LVNs. For RNs, the salary range is $34 - $38/hr. This salary range represents our national target range for this role.

Astrana Health is proud to be an Equal Employment Opportunity and Affirmative 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.