Utilization Management Outpatient Authorization Nurse

Utilization Management Outpatient Authorization Nurse Champion Health Plan is a Medicare Advantage Prescription Drug

HMO C-SNP

serving Medicare beneficiaries with End-Stage Renal Disease. Long Beach, CA Job Details Full-time From $67,000 a year 1 day ago Benefits Health insurance Dental insurance 401(k) Vision insurance Life insurance Qualifications Nursing LVN Outpatient Bachelor's degree Utilization management Attention to detail Decision making Organizational skills Nursing Time management Full Job Description Job Overview The Utilization Management Pre-Authorization Nurse is responsible for managing outpatient utilization by conducting thorough reviews of clinical documentation and applying clinical knowledge in accordance with Milliman Care Guidelines (MCG), InterQual Criteria, Medicare Advantage (MCAL), 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, including CMS, Department of Health Care Services (DHCS), and Department of Managed Health Care (DMHC) requirements. The nurse also issues timely and accurate denial, deferral, or authorization letters, manages clinical review processes, and supports compliance with health plan guidelines.

KEY RESPONSIBILITIES

Manage all authorizations, deferrals, and denials by conducting comprehensive reviews of clinical documentation, applying clinical criteria and guidelines such as MCG, InterQual, UpToDate, and CMS. Review authorizations, deferrals, and denials 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 authorizations, deferrals, and denials in compliance with company and departmental policies and procedures. Process 30-40 deferral or denial letters daily with accuracy, maintaining high standards of quality. Review and process denials, modifications, and carve-outs according to established procedures and clinical criteria. Use clinical expertise to apply MCG, InterQual, and other 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. Comply with internal policies and procedures to ensure timely and accurate processing of all deferrals, denials, and modification requests. Stay up-to-date with changes in regulatory requirements (CMS, DMHC, DHCS) and integrate new policies into daily processes. Perform additional duties, projects, and actions as assigned to support department goals and operational needs.

QUALIFICATIONS

Education Licensed Vocational Nurse (LVN) with an active, unrestricted license in the state of practice. Bachelor's degree in Nursing (preferred, but not required). Experience Minimum of 3 years of clinical nursing experience, with a focus on Utilization Management or managed care preferred. Familiarity with Milliman Care Guidelines (MCG), InterQual, Medicare, Medicaid, and CMS regulations. Utilization management experience with a Health Plan or Management Services Organization (MSO). Knowledge, Skills, and Abilities Strong knowledge of MCG, InterQual 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 deferral and denial letters 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, attention to detail, and sound decision-making skills required. Ability to manage multiple projects of varying complexity, priority levels, and deadlines. Proficient knowledge of Health Plan, DMHC, DHCS, CMS, HIPAA, and NCQA requirements.

PROFESSIONAL COMPETENCIES

Strong problem-solving skills with the ability to analyze and apply clinical guidelines and policies. Excellent organizational and time management skills to meet deadlines while maintaining accuracy. Ability to thrive in a fast-paced, results-driven environment.

WORK ENVIRONMENT AND PHYSICAL REQUIREMENTS

The majority of work responsibilities are performed in an office setting, working on a computer. Regularly required to talk, hear, stand, walk, sit, and use hands to handle or feel objects and controls.

Job Type:

Full-time Pay:

From $67,000.00 per year

Benefits:

401(k) Dental insurance Health insurance Life insurance Vision insurance

Experience:

Outpatient:

3 years (Required) Utilization management: 3 years (Preferred)

License/Certification:

LVN (Preferred)

Location:

Long Beach, CA 90815 (Required)

Work Location:

In person