UM 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

BENEFITS:

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