UM Outpatient Review Nurse

All Care To You•Orange, CA

6d•$70,000 - $120,000•Remote

About The Position

All Care To You (ACTY) is a Management Service Organization that provides healthcare administrative support to Independent Physician Associations, TPAs, and Fiscal Intermediary clients. The company describes itself as modern and growing, with a culture centered on teamwork, support, inclusion, curiosity, initiative, and making a difference. It operates fully remotely and offers flexible work schedules. The UM Outpatient Review Nurse reports to the Director, Case Management and is part of the Case Management team. The role supports clinical quality and patient outcomes by applying utilization review best practices and State, Federal, health plan, and clinical guidelines to determine medical necessity. The nurse reviews and processes authorization requests, makes approval determinations when criteria are met, and refers cases to the Medical Director when appropriate. The position also supports clinical coordination and communication with health plans, providers, members, and other parties.

Requirements

Current, unrestricted California and Texas/multistate Registered Nurse or Licensed Vocational Nurse license.
Five or more years of clinical experience.
CM and/or UM training and/or certification.
Knowledge of case management standards, utilization management standards, clinical standards of care, NCQA requirements, CMS guidelines, Milliman guidelines, and InterQual guidelines.
Ability to work independently with minimal supervision and exercise judgment and initiative.
Ability to manage multiple tasks and prioritize effectively.
Proficiency with Outlook, Microsoft Teams, Zoom, Microsoft Office, including Word and Excel, and Adobe.
Availability to work weekends and holidays as business needs require.
Detail-oriented and highly organized.
Strong multitasking, project management, and fast-paced work skills.
Strong problem-solving ability.
Self-management and strong time-management skills.
Ability to work in an extremely confidential environment.
Strong written and verbal communication skills.

Nice To Haves

Two or more years of experience in an HMO, IPA, or managed care setting is preferred and recommended.
Experience interpreting Medi-Cal, commercial, and Medicare contracts and benefits is preferred.

Responsibilities

Review authorization requests for medical necessity and determine which requests require Medical Director review.
Obtain sufficient medical documentation for informed review and attach clinical documentation, applicable criteria, and records before referring cases to the Medical Director.
Process requests and denials within established time frames and document each process step in the authorization system.
Apply CMS and health plan hierarchy criteria, clinical criteria and guidelines, policies, EOC/benefit policies, and clinical judgment to coverage determinations or recommendations.
Conduct retrospective reviews of services to determine medical necessity.
Write denial letters that meet CMS and health plan requirements.
Review members’ utilization and claim history when processing referrals.
Maintain quality reviews while meeting turnaround times for urgent, routine, and retrospective requests.
Maintain an interrater reliability rate of at least 95% and meet the daily production standard of 50–90 referrals, depending on complexity, while maintaining accuracy and quality.
Make approval determinations when requests meet appropriateness, medical necessity, and benefit criteria.
Use clinical experience in a collaborative process to assess, plan, implement, coordinate, monitor, and evaluate options for appropriate healthcare services that meet criteria and can be authorized by a nurse-level reviewer.
Serve as a clinical resource to all departments.
Communicate with health plans, providers, members, and other parties to facilitate member care treatment plans.
Work with other MSO team members as needed and participate in team training.
Comply with UM policies and procedures, complete annual policy reviews, and attend provider and interdepartmental calls while providing exceptional customer service.
Maintain strict confidentiality and discretion when handling sensitive provider and member matters.
Perform other duties as needed.