UM Review Nurse - 1641

$62,400 - $70,720/Yr

Astrana Health - Monterey Park, CA

Full-time - Mid Level

Hybrid - Monterey Park, CA

5,001-10,000 employees

About the position

The Utilization Review Nurse at Astrana Health plays a crucial role in the Health Services Department by utilizing clinical judgment to approve or deny medical services based on Medical Necessity Criteria for various Health Plans. This hybrid position involves both in-office and remote work, with a typical schedule of Monday to Friday and occasional Saturday shifts.

Responsibilities

• Complete prior authorization/retrospective review of elective inpatient admissions, outpatient procedures, post-homecare services, and durable medical equipment.
• Refer cases to Medical Directors as needed/appropriate.
• Maintain knowledge of state and federal regulations and accreditation standards.
• Comply with internal policies and procedures.
• Perform any other job duties as requested.

Requirements

• Active and unrestricted LVN license in California.
• Two (2) years of health plan, IPA or MSO experience.
• Experience with Microsoft applications such as Word, Excel, and Outlook.
• Strong interpersonal skills.
• Ability to collaborate with co-workers, senior leadership, and other management.
• Experience educating and training staff.

Benefits

• Health insurance