About the job
Medix is seeking fully REMOTE Utilization Review Nurses for a growing healthcare organization!
MUST HOLD CALIFORNIA RN OR LVN LICENSE
Shift:
- Tues – Sat (8am – 5pm PT)
- Sun – Thurs (8am – 5pm PT)
Pay: $37 – $48 (DOE)
Position Summary
The Utilization Management (UM) Nurse – Pre-Service is responsible for reviewing pre-certification requests for inpatient and outpatient services for all plan members. This role collaborates with providers, regional and senior medical directors to ensure timely processing of referrals and delivery of high-quality, cost-efficient care.
Key Responsibilities
- Review pre-certification requests for medical necessity; refer to Medical Director as needed.
- Utilize CMS guidelines (LCD, NCD) and Milliman Care Guidelines (MCG) for determinations.
- Maintain turnaround time (TAT) goals for referral processing.
- Initiate single service agreements (SSA) for out-of-network services.
- Maintain professional rapport with providers, physicians, and support staff.
- Verify member eligibility and benefit coverage.
- Confirm accuracy of ICD-10 and CPT coding for pre-certification requests.
- Request necessary medical records and documentation from providers.
- Review referral denials for appropriate guideline application and language.
- Assist Medical Directors with appeals and grievances.
- Contact members and document calls for expedited requests.
- Perform other duties as assigned.
Qualifications
- Active, unrestricted RN or LVN license in California
- 1+ year of UM experience (pre-service).
- 1+ year in managed care (Medicaid and/or Medicare).
- 1+ year applying UM criteria (CMS LCD/NCD).
- 1+ year experience working with IPAs, referrals, or prior authorizations.
- 1+ year experience applying clinical criteria (MCG)
California applicants: We will consider for employment all qualified Applicants, including those with criminal histories, in a manner consistent with the requirements of applicable federal, state and local laws, including the City of Los Angeles’ Fair Chance Initiative for Hiring Ordinance (FCIHO), Los Angeles Fair Chance Ordinance for Employers (ULAC), The San Francisco Fair Chance Ordinance (FCO) , and the California Fair Chance Act (CFCA).
This position is subject to a background check based on its job duties, which may include patient care, working with vulnerable populations, access to financial and confidential information, driving, working with heavy machinery, or working in a warehouse or laboratory environment. Due to these job duties, this position has a significant impact on the business operations and reputation, as well as the safety and well-being of individuals who may be cared for as part of the job position or who may interact with staff or clients.