Utilization Management Nurse, RN

Altais•Remote - CA, CA

2d•$45 - $54

About The Position

About Altais: At Altais, we’re on a mission to improve the healthcare experience for everyone—starting with the people who deliver it. We believe physicians should spend more time with patients and less time on administrative tasks. Through smarter technology, purpose-built tools, and a team-based model of care, we help doctors do what they do best: care for people. Altais includes a network of physician-led organizations across California, including Brown & Toland Physicians, Altais Medical Group Riverside, and Family Care Specialists. Together, we’re building a stronger, more connected healthcare system. About the Role Are you looking to join a fast-growing, dynamic team? We’re a collaborative, purpose-driven group that’s passionate about transforming healthcare from the inside out. At Altais, we support one another, adapt quickly, and work with integrity as we build a better experience for physicians and their patients. As a Utilization Management RN, you'll work closely with our Ambulatory and Concurrent Care, Network Management, Quality Improvement, and Practice Success teams. Your responsibilities include driving efficient authorization processes, navigating insurance requirements with precision and advocacy. We seek individuals with a strong commitment to patient-centered care and a passion for promoting health and wellness.

Requirements

RN-Registered Nurse of California Licensure required.
2 years recent relevant experience.

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.