UM Outpatient Review Nurse

All Care To You is a Management Service Organization providing our clients with healthcare administrative support. We provide services to Independent Physician Associations, TPAs, and Fiscal Intermediary clients. ACTY is a modern growing company which encourages diverse perspectives. We celebrate curiosity, initiative, drive and a passion for making a difference. We support a culture focused on teamwork, support, and inclusion. Our company is fully remote and offers a flexible work environment as well as schedules.

ACTY offers 100% employer paid medical, vision, dental, and life coverage for our employees. Additional employee paid coverage options available. We also offer paid holidays, birthday off, and unlimited PTO as well as a 401k plan.

The position of UM Outpatient Review Nurse reports to the Director, Case Management. The position of UM Outpatient Review Nurse is part of the Case Management team and is responsible for clinical, quality, and patient outcomes. This position is expected to implement the effectiveness and best practices of Utilization Review and will provide high quality medical review by appropriately applying the State, Federal, health plan and clinical guidelines used to determine medical necessity.

• Review authorization requests for medical necessity, determines which requests need Medical Director review, obtains sufficient medical documentation for an informed consent.
• Process all requests within established time frames.
• Documents all steps of process in authorization system in the authorization notes.
• Utilizes CMS and Health Plan Hierarchy criteria.
• Clinical documentation, specific criteria, and record attachment for referral prior to sending to the Medical Director for review.
• Retrospective review of services to determine medical necessity.
• Refer cases to the Medical Director for review of requests that may not meet medical necessity criteria.
• Process denials within established time frames.
• Writes denial letters to meet CMS and Health Plan requirements.
• Work closely with other MSO team members as necessity requires.
• Applies the appropriate clinical criteria/guideline, policy, EOC/benefit policy and clinical judgment to render coverage determination/recommendation for the review process.
• Review member’s utilization and claim history when processing a referral.
• Maintain quality reviews while meeting the established TATs for Urgent, Routines and Retro requests.
• Maintains Interrater Reliability Rate at least 95% or above.
• Daily production standard is a minimum of 50-90 referrals/day depending on complexity with accuracy & quality.
• Makes approval determinations when request meets appropriateness, medical necessity and benefit criteria.
• Utilizes clinical experience and skills in a collaborative process to assess, plan, implement, coordinate, monitor and evaluate options to facilitate appropriate healthcare services that meet criteria and can be authorized by a nurse level reviewer.
• Act as clinical resource to all departments.
• Communicates with health plans, providers, members and other parties to facilitate member care treatment plans.
• Participating in team training
• Comply with UM policies and procedures. Annual review of UM policies. Attend to provider and interdepartmental calls in accordance with exceptional customer service.
• Ability to keep high level of confidence and discretion when dealing with sensitive matters relating to providers, and members. Always maintains strict confidentiality.
• Other duties as needed.

• A valid CA and Texas/Multi State Registered Nurse license or Licensed Vocational Nurse
• CM and/or UM training and/or certification. Knowledge of CM standards, UM standards, Clinical Standards of Care, NCQA requirements, CMS guidelines, Milliman guidelines, and Inter Qual guidelines. Medi-Cal, Commercial and Medicare contracts and benefit interpretation is preferred.
• Five years+ clinical experience.
• Prefer of two (2) years+ experience in an HMO/IPA/Managed care setting is preferred and recommended.
• Must be available to work weekends and holidays, as business needs require.
• Ability to work independently with minimal supervision, exercising judgment and initiative.
• Ability to manage multiple tasks with effective prioritization.
• Proficiency using Outlook, Microsoft Teams, Zoom, Microsoft Office (including Word and Excel) and Adobe
• Must be available to work weekends and holidays, as business needs require.
• Detail oriented and highly organized
• Strong ability to…