Denial Review Nurse - Hybrid

$62,400 - $93,600/Yr

Astrana Health - Monterey Park, CA

Full-time - Mid Level

Hybrid - Monterey Park, CA

About the position

We are currently seeking a highly motivated Denial Review Nurse to join our Health Services - Denials department at Astrana Health. This role is crucial in managing all deferrals and denials by conducting comprehensive reviews of clinical documentation, clinical criteria, guidelines, and policies. The Denial Review Nurse will report directly to the Manager - Denials and will play a key role in our efforts to scale within the healthcare industry. In this position, you will apply your clinical knowledge to process all deferrals and denials, ensuring compliance with clinical criteria, including but not limited to DMHC, DHCS, CMS, Health Plan, Milliman Care Guidelines (MCG), and UpToDate. You will be responsible for adhering to company and department policies to ensure timely and accurate processing of all cases. On a daily basis, you will review and process assigned deferrals or denials, which may include denial, modification, or carve-out, with a target of processing 30-40 letters per day while maintaining high standards of accuracy and quality. Additionally, you will be expected to perform other duties, projects, and actions as assigned, contributing to the overall efficiency and effectiveness of the department. This role offers a unique opportunity to work in a hybrid environment, transitioning to a flexible work schedule after a probationary period, while being part of a company that is committed to improving patient outcomes and increasing access to healthcare.

Responsibilities

• Manage all deferrals and denials by conducting comprehensive reviews of clinical documentation, clinical criteria, guidelines, and policies.
• Apply clinical knowledge when processing all deferrals and denials, supported by clinical criteria including DMHC, DHCS, CMS, Health Plan, MCG, and UpToDate.
• Comply with company and department policies and procedures to ensure timely and accurate processing of all deferrals and denials.
• Review and process daily assigned deferrals or denials with a target of 30-40 letters per day, ensuring accuracy and quality.
• Perform other duties, projects, and actions as assigned.

Requirements

• Possession of an active, unrestricted, and current California Registered Nurse (RN) or Licensed Vocational Nurse (LVN) license.
• Proficient in Microsoft Office applications.
• Strong written and oral communication skills.
• Exceptional follow-through abilities to track outstanding tasks and coordinate with assigned owners.
• Strong organizational skills, detail-oriented, and sound decision-making skills required.
• Ability to manage multiple projects of varying complexity, priority levels, and deadlines.
• Utilization management experience with a Health Plan or MSO.
• Proficient knowledge of Health Plan, DMHC, DHCS, CMS, HIPAA, and NCQA requirements.

Benefits

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