Utilization Review Nurse - Denials

Job Description

Job Description

Description

Astrana Health is looking for a Utilization Review Nurse to assist our Health Services Department in reviewing referral / authorization denials and ensuring patients do not meet medical necessity criteria for denied services. Candidates must be available to work 365 days a year to account for the rotating weekend and holiday coverage schedule. This is a hybrid role where the expectation is to work both in office and at home on a weekly basis.

We are seeking nurses who have prior UM experience or knowledge of managed care! If you are interested in a denials-focused position and pride yourself on thriving in fast-paced environments, we encourage you to apply!

What You'll Do

• Complete reviews of denied claims and associated medical records to determine validity of denials for elective inpatient admissions, outpatient procedures, post-homecare services, and durable medical equipment, based on clinical documentation and payor policies
• Prepare and submit denial letters supported by clinical rationale, industry guidelines, and payer-specific criteria
• Collaborate with UM team, providers, and other departments to clarify documentation or cording as needed for rationale support
• Refer cases to Medical Directors as needed / appropriate
• Maintain knowledge of state and federal regulations and accreditation standards
• Comply with internal policies and procedures
• Perform any other job duties as requested

Qualifications

You’ll be Great for this Role If :

Environmental Job Requirements and Working Conditions

Astrana Health is proud to be an Equal Employment Opportunity and Affirmative Action employer. We do not discriminate based upon race, religion, color, national origin, gender (including pregnancy, childbirth, or related medical conditions), sexual orientation, gender identity, gender expression, age, status as a protected veteran, status as an individual with a disability, or other applicable legally protected characteristics. All employment is decided on the basis of qualifications, merit, and business need. If you require assistance in applying for open positions due to a disability, please email us at humanresourcesdept@networkmedicalmanagement.com to request accommodation.

Additional Information :

The job description does not constitute an employment agreement between the employer and employee and is subject to change by the employer as the needs of the employer and requirements of the job change.