Utilization Management Nurse Reviewer

Astiva Health, Inc., located in Orange, CA is a premier healthcare provider specializing in Medicare and HMO services. With a focus on delivering comprehensive care tailored to the needs of our diverse community, we prioritize accessibility, affordability, and quality in all aspects of our services. Join us in our mission to transform healthcare delivery and make a meaningful difference in the lives of our members.

The Utilization Management Authorization Review Nurse is responsible for managing inpatient & outpatient utilization by conducting thorough reviews of clinical documentation and applying clinical knowledge in accordance with relevant Care Guidelines and CMS regulations. This role ensures that all authorizations, deferrals, and denials are processed efficiently, accurately, and in compliance with company policies and regulatory standards. The nurse also issues timely and accurate denial, deferral, or authorization letters, manages clinical & concurrent review processes, and supports compliance with health plan guidelines.

• Manage all authorizations, deferrals, and denials by conducting comprehensive reviews of clinical documentation, applying clinical criteria and guidelines.
• Review authorization requests for medical necessity, ensuring adherence to regulatory and health plan criteria, policies, and Evidence of Coverage (EOC).
• Apply clinical knowledge when processing deferrals and denials, supported by regulatory guidelines from CMS, DMHC, DHCS, and health plan policies.
• Ensure timely and accurate processing of all authorization requests in compliance with company and departmental policies and procedures.
• Review and process denials, modifications, and carve-outs according to established procedures and clinical criteria.
• Use clinical expertise to apply relevant clinical guidelines to ensure that medical decisions align with best practices and regulations.
• Review all applicable benefit policies and Evidence of Coverage (EOC) to ensure accurate decisions regarding coverage and medical necessity.
• Collaborate with healthcare providers, the Utilization Management (UM) team, and compliance departments to ensure clear communication and appropriate utilization of healthcare services.
• Coordinate with the Appeals team to support the completion of appeal and denial letters as needed.
• Perform additional duties, projects, and actions assigned to support department goals and operational needs.
• Regular and consistent attendance.
• Other duties as assigned

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily, including regular and consistent attendance. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• Licensed Vocational Nurse (LVN) with an active, unrestricted license in the state of practice.
• Bachelor’s Degree in Nursing preferred.
• Minimum of 3 years of clinical nursing experience, with a focus on Utilization Management or managed care preferred.
• Familiarity with Milliman Care Guidelines (MCG), Inter Qual, Medicare, Medicaid, and CMS regulations.
• Utilization management experience with a Health Plan or Management Services Organization (MSO).
• Strong knowledge of MCG, Inter Qual Criteria, Medicare (MCAL), and CMS guidelines.
• Proficient in applying clinical knowledge to support medical necessity decisions based on health plan policies, benefit guidelines, and regulatory criteria.
• Excellent organizational skills and the ability to process a high volume of authorization requests with accuracy and attention to detail.
• Strong communication skills, both verbal and written, especially in creating clear and compliant deferral and denial letters.
• Ability to collaborate with cross-functional teams, including providers and internal UM teams.
• Exceptional follow-through abilities to track all outstanding tasks and coordinate with assigned owners to ensure tasks are completed in a timely manner.
• Strong organizational skills,…