Denial Review Nurse - 1464

$62,400 - $93,600/Yr

Astrana Health - Monterey Park, CA

Full-time - Mid Level

Hybrid - Monterey Park, CA

5,001-10,000 employees

About the position

The Denial Review Nurse at Astrana Health is responsible for reviewing denied claims from the Utilization Management (UM) team, ensuring compliance with clinical guidelines and policies. This role requires a strong background in Utilization Management and offers a hybrid work schedule after a probationary period. The position is crucial for managing deferrals and denials, contributing to the company's mission of improving patient outcomes and healthcare efficiency.

Responsibilities

• Manage all deferrals and denials by conducting comprehensive reviews of clinical documentation and criteria.
• Apply clinical knowledge when processing deferrals and denials, supported by clinical criteria.
• Comply with company and department policies to ensure timely processing of all claims.
• Review and process daily assigned deferrals or denials with accuracy and quality, handling 30-40 letters per day.
• Perform other duties, projects, and actions as assigned.

Requirements

• Possession of an active, unrestricted California Registered Nurse (RN) or Licensed Vocational Nurse (LVN) license.
• Proficient in Microsoft Office applications.
• Strong written and oral communication skills.
• Utilization management experience with a Health Plan or MSO.
• Proficient knowledge of Health Plan, DMHC, DHCS, CMS, HIPAA, and NCQA requirements.

Nice-to-haves

• Exceptional follow-through abilities to track outstanding tasks and coordinate with assigned owners.
• Strong organizational skills and attention to detail.
• Ability to manage multiple projects of varying complexity and deadlines.

Benefits

• Ample opportunity for overtime pay.
• Hybrid work schedule after probationary period.