About Us
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.
Job purpose
The position of UM Nurse Reviewer reports to the UM Nurse Manager. The position of UM Nurse Reviewer is part of the Case Management team and is responsible for the 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 or clinical guidelines used to determine medical necessity.
Duties and responsibilities
· Must hold an unrestricted RN or LVN nursing license
· Comply with UM policies and procedures. Annual review of UM policies.
· Review authorization requests for DME, Ancillary and Medical authorization based off of established guidelines
· Review requests for inpatient hospitalization, Acute Rehab, Skilled Nursing Facility authorizations based on established guidelines
· Retrospective review of services to determine medical necessity
· Refer cases to the Chief Medical Officer or Medical Director for review of requests that may not meet medical necessity criteria
· Work closely with other MSO team members as necessity requires
· Review & screen incoming service referral requests for medical necessity.
· Applies the appropriate clinical criteria/guideline, policy, EOC/benefit policy and clinical judgment to render coverage determination/recommendation for the review process.
· Review member' utilization and claim history when processing a referral.
· Clinical documentation, specific criteria, and record attachment for referral prior to sending to the Medical Director for review.
· Maintain quality reviews while meeting the established TATs for Urgent, Routines and Retro requests.
· 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 meets 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 plan.
· Participate in team trainings
· 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 strictest confidentiality.
· Other duties as needed.
Qualifications
· Valid 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 InterQual 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.
· 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
· Detail oriented and highly organized
· Strong ability to multi-task, project management, and work in a fast-paced environment
· Strong ability in problem-solving
· Ability to self-manage, strong time management skills
· Ability to work in an extremely confidential environment
· Strong written and verbal communication skills
Education and Additional Requirements
· Holds Current Unrestricted CA and/or Texas/Multi State RN or LVN.
Working conditions
· This job may require flexible work hours due to the nature of the responsibilities
· Candidate must be comfortable with ambiguity and open to working in a collaborate environment
Physical requirements
· Sitting/standing for extended periods of time.
Salary Range
· $90,000 - $130,000 annually (RN)
· $70,000 - $95,000 annually (LVN)
Job Type: Full-time
Pay: $70,000.00 - $130,000.00 per year
Benefits:
- 401(k)
- 401(k) matching
- Dental insurance
- Employee assistance program
- Flexible spending account
- Health insurance
- Life insurance
- Paid time off
- Vision insurance
Schedule:
- Day shift
- Monday to Friday
Application Question(s):
- Do you have a current Unrestricted CA and/or Texas/Multi State RN or LVN License?
Experience:
- HMO/IPA/Managed care setting: 2 years (Preferred)
Work Location: Remote