Job detail

UM Review Nurse

Astrana Health, Inc.

#MSO #Durable Medical Equipment #Healthcare Compliance #Prior Authorization #Outpatient Services #Medical Necessity #IPA #Utilization Management #Health Plan

Quick overview

The role involves performing prior authorization and retrospective reviews of medical services based on Medical Necessity Criteria. The nurse will refer complex cases to Medical Directors and ensure compliance with state and federal regulations.

Requirements summary

Candidates must hold an active and unrestricted CA LVN license and have at least one year of outpatient Utilization Management experience. Proficiency in Microsoft Office applications and residency in California are required.

professional certificateInterpersonal SkillsStaff TrainingCollaborationMicrosoft ExcelMicrosoft WordMicrosoft OutlookUtilization ReviewPrior AuthorizationClinical JudgementMedical Necessity CriteriaRetrospective Review

Job description

UM Review Nurse Department

HS -
UM
Employment
Type:
Full
Time
Location: 1600 Corporate Center Dr.,
Monterey
Park,
CA 91754
Reporting To:
Sandra
Castellon
Compensation: $34.00 - $42.00 / hour

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 position requires open availability between Monday through Sunday, 8 A - 8 P. You would be scheduled for 5 shifts per week. 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 license in CA. 1+ years of outpatient UM experience 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 - $42.00 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 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 humanresourcesdept@astranahealth.com 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.