Clinical Guide: (UM) Utilization Management Nurse (Outpatient Prior Authorization)

As a Clinical Guide on our Outpatient Utilization Management team, you’ll have the opportunity to make a difference in the lives of our members.

Description

• Review requests across multiple authorization categories including outpatient procedures, imaging, therapy, DME, and home health.
• Determine the appropriateness of requested services and recommend clinically appropriate alternatives.
• Communicate with providers and internal teams to obtain additional clinical documentation.
• Maintain accurate documentation of every determination in line with CMS regulations.

Requirements

• An unrestricted RN license with a minimum of 4 years of RN experience.
• Minimum 3 years of utilization management, utilization review, or prior authorization experience.
• Knowledge and understanding of CMS guidelines and Medicare Advantage requirements.
• Experience escalating cases that do not meet criteria, including preparing clinical summaries for physician review.
• Comfort in a fast-paced environment with daily turnaround standards.

Benefits

• Employer sponsored health, dental and vision plan with low or no premium.
• Generous paid time off.
• $100 monthly mobile or internet stipend.
• Stock options for all employees.
• Bonus eligibility for all roles excluding Director and above.
• Parental leave program.
• 401K program.
• Conduct timely, comprehensive clinical review of outpatient authorization requests, applying evidence-based medical necessity criteria.
• Refer cases that do not meet criteria to the Medical Director for secondary review and prepare clinical summaries.