Utilization Management Nurse, LVN - Casual

Altais•Remote - CA, CA

3d•$36 - $43

About The Position

Altais is seeking a Utilization Management LVN for a casual, 6-month contract opportunity. This role involves working closely with various internal teams to drive efficient authorization processes and navigate insurance requirements. The ideal candidate will have a strong commitment to patient-centered care and a passion for promoting health and wellness. Altais is a growing, dynamic organization focused on transforming healthcare by supporting physicians and improving the patient experience.

Requirements

LVN - Licensed Vocational Nurse of California Licensure required.
2 years recent relevant experience.
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.

Nice To Haves

Awareness of healthcare reimbursement systems: HMO, PPO, PPS, CMA, all value-based reimbursement models, and alternative payment systems preferred.
Prior MSO experience preferred.
Recent MCG or InterQual experience highly desired.
Experience with ICD-9, CPT and HCPCS codes preferred.

Responsibilities

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 requirements.
Ensure accuracy of case data in Tapestry including ICD-10, CPT and HCPC codes.
Participate 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.