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Clinical Guide: (UM) Utilization Management Nurse (Outpatient Prior Authorization)

πŸ•’ 11 days ago
Clinical ReviewOutpatient AuthorizationEvidence-based CriteriaCMS Guidelines

πŸ“œ Description

  • Review requests across multiple authorization categories including outpatient procedures, imaging, therapy, DME, and home health.
  • Determine the appropriateness of requested services and recommend clinically appropriate alternatives.
  • Communicate with providers and internal teams to obtain additional clinical documentation.
  • Maintain accurate documentation of every determination in line with CMS regulations.

πŸ› οΈ Requirements

  • An unrestricted RN license with a minimum of 4 years of RN experience.
  • Minimum 3 years of utilization management, utilization review, or prior authorization experience.
  • Knowledge and understanding of CMS guidelines and Medicare Advantage requirements.
  • Experience escalating cases that do not meet criteria, including preparing clinical summaries for physician review.
  • Comfort in a fast-paced environment with daily turnaround standards.

✨ Benefits

  • Employer sponsored health, dental and vision plan with low or no premium.
  • Generous paid time off.
  • $100 monthly mobile or internet stipend.
  • Stock options for all employees.
  • Bonus eligibility for all roles excluding Director and above.
  • Parental leave program.
  • 401K program.
  • Conduct timely, comprehensive clinical review of outpatient authorization requests, applying evidence-based medical necessity criteria.
  • Refer cases that do not meet criteria to the Medical Director for secondary review and prepare clinical summaries.

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