Utilization Management Nurse Reviewer

About Us:

Astiva Health, Inc., located in Orange, CA is a premier healthcare provider specializing in Medicare and HMO services. With a focus on delivering comprehensive care tailored to the needs of our diverse community, we prioritize accessibility, affordability, and quality in all aspects of our services. Join us in our mission to transform healthcare delivery and make a meaningful difference in the lives of our members.

SUMMARY: The Utilization Management Authorization Review Nurse is responsible for managing inpatient & outpatient utilization by conducting thorough reviews of clinical documentation and applying clinical knowledge in accordance with relevant Care Guidelines 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. The nurse also issues timely and accurate denial, deferral, or authorization letters, manages clinical & concurrent review processes, and supports compliance with health plan guidelines.

ESSENTIAL DUTIES AND RESPONSIBILITIES include the following:

• Manage all authorizations, deferrals, and denials by conducting comprehensive reviews of clinical documentation, applying clinical criteria and guidelines.
• Review authorization requests 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 authorization requests in compliance with company and departmental policies and procedures.
• Review and process denials, modifications, and carve-outs according to established procedures and clinical criteria.
• Use clinical expertise to apply 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.
• Perform additional duties, projects, and actions assigned to support department goals and operational needs.
• Regular and consistent attendance.
• Other duties as assigned

QUALIFICATION REQUIREMENTS : To perform this job successfully, an individual must be able to perform each essential duty satisfactorily, including regular and consistent attendance. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

EDUCATION and/or EXPERIENCE :

• Licensed Vocational Nurse (LVN) with an active, unrestricted license in the state of practice.
• Bachelor’s Degree in Nursing preferred.
• 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).
• 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 authorization requests 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.

BENEFITS:

• 401(k)
• Dental Insurance
• Health Insurance
• Life Insurance
• Vision Insurance
• Paid Time Off

LANGUAGE: Ability to read and interpret documents such as safety rules, operating and maintenance instructions, and procedure manuals. Ability to write routine reports and correspondence. Ability to speak effectively before groups and customers or employees of the organization.

MATHEMATICS: Ability to add, subtract, multiply, and divide in all units of measure, using whole numbers, common fractions, and decimals. Ability to compute rate, ratio, and percent and to draw and interpret bar graphs.

REASONING ABILITY: Ability to solve practical problems and deal with a variety of concrete variables in situations where only limited standardization exists. Ability to interpret a variety of instructions furnished in written, oral, diagram or schedule form.

EEO/AFFIRMATIVE ACTION STATEMENT: It is the policy of Astiva Health to provide equal employment opportunities without regard to race, color, religion, sex, national origin, age, disability, marital status, veteran status, sexual orientation, genetic information or any other protected characteristic under applicable law.This policy relates to all phases of employment, including but not limited to recruiting, employment, placement, promotion, transfer, demotion, reduction of workforce and termination, rates of pay or other forms of compensation, selection for training, the use of all facilities, and participation in all company sponsored employee activities. Provisions in applicable laws providing for bona fide occupational qualifications, business necessity or age limitations will be adhered to by the organization where appropriate. Please refer to Standard Operating Procedure 100 for more information about the organization’s Affirmative Action/EEO statement.

PHYSICAL DEMANDS : The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this job, the employee is frequently required to sit and complete work while on a computer.The employee occasionally is required to stand, walk, use hands to finger, handle or feel, reach with hands and arms, stoop, kneel, crouch or crawl, climb or balance, talk and hear.

While performing the duties of this job, the employee is occasionally required to lift or exert force up to 10 pounds.

WORK ENVIRONMENT : The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

The noise level in the work environment is usually moderate.

Employee signature below indicates the employee’s understanding of the requirements, essential functions and duties of this position.