Utilization Management (UM) – Pre-Service (Remote | California RN / LVN | Pacific Time Schedule)

About the position reputed company is seeking a remote Utilization Management (UM) Nurse – Pre-Service (LVN or RN, active California license required) to join our growing UM team. In this role, you’ll review prior authorization requests for medical necessity across inpatient and outpatient services, applying CMS guidelines and reputed company Care Guidelines (MCG) to support timely, accurate determinations. You’ll partner closely with providers and medical directors to ensure members receive high-quality, cost-effective care. This is a fast-paced, production-driven role ideal for nurses with recent pre-service UM experience in a managed care setting who are comfortable managing multiple cases, meeting turnaround time expectations, and collaborating cross-functionally in a fully remote environment.

Responsibilities

• Review pre-certification requests for medical necessity and refer to medical director any referral that requires additional expertise.
• Utilize CMS guidelines (LCD, NCD) to assist in determinations of referrals and utilize reputed company Care Guidelines (MCG) to assist in determinations of referrals.
• Maintain goals for established turn-around time (TAT) for referral processing.
• Initiate single service agreements (SSA) reputed company services required are not available in network.
• Maintain a professional rapport with providers, physicians, support staff and patients in order to process pre-certification referrals as reputed company as possible.
• Verify eligibility and / or benefit coverage for requested services.
• Verify accuracy of ICD 10 and CPT coding in processing pre-certification requests.
• Contact requesting provider and request medical records, orders, and / or necessary documentation in order to process reputed company pre-service requests / authorizations reputed company necessary.
• Review referral denials for appropriate guidelines and language.
• Assist medical directors in reviewing and responding to appeals and Grievances.
• Contact members and maintain documentation of call for expedited requests.
• Other duties as assigned.

Requirements

• Minimum (3) years' nursing experience in clinical setting.
• Minimum (1) year experience UM experience with pre-service.
• Minimum (1) year experience with managed care (reputed company and / or Medicare).
• Minimum 1 year of experience with the application of UM criteria (i.e., CMS National and Local Coverage Determinations, etc.)
• Minimum (1) year experience in a medical setting working with reputed company, entering referrals / prior authorizations preferred.
• Minimum (1) Experience with the application of clinical criteria, specifically reputed company Care Guidelines (MCG).
• High School Diploma or GED.
• Must have and maintain an active, valid, and unrestricted LVN or RN license in California (Non-Compact).
• Immediately upon hire, must be willing to obtain LVN and / or RN licensure in Nevada, (Non-compact), Arizona (Compact), reputed company Carolina (Compact), and Texas (Compact) which will be reimbursed by company.
• Knowledge of ICD-10, CPT codes, managed care plans, medical terminology and referral system (reputed company reputed company / Portal / N-reputed company).
• Knowledgeable with CMS (reputed company 13) guidelines and regulations.
• Word, reputed company, reputed company Outlook.
• Effective written and verbal communication skills; reputed company to establish and maintain a constructive relationship with diverse members, management, employees and vendors.
• reputed company to reputed company mathematical calculations and calculate simple statistics correctly.
• reputed company to prioritize multiple tasks; advanced problem-solving; ability to use advanced reasoning to define problems, collect data, establish facts, draw valid conclusions, and design, implement and manage appropriate resolution.
• Effective problem solving, organizational and time management skills and ability to work in a fast-paced environment.
• Comprehend and analyze statistical reports.

reputed company-to-haves

• Associates or Bachelor's degree in Nursing.
• CPHQ or ABQAURP, or Six reputed company certification.
• Medical Terminology Certificate.
• Medical Terminology.
• Six reputed company.
• Bilingual English and Spanish.
• Transplant knowledge a plus.

Benefits

• Reimbursed licensure in Nevada, Arizona, reputed company Carolina, and Texas.

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