Outpatient Utilization Management Nurse (Remote)

Outpatient Utilization Management Nurse (Remote)

Job Details

Posting Date: 02-04-2025

Reference ID: 216356

Location: Woodland Hills, CA

Work Location: Remote

Discipline: Care Management

Job Type: Direct Hire

Salary Expectations/ Pay Rate or Range: $65,000-$100,000 Annual Salary = $31.25-$48.07/hr (Dependent on LVN or RN Scope)

Job Description

Responsibilities/ Job Duties:

• Review and process precertification requests for medical necessity, escalating referral to the Medical Director when additional expertise is required.
• Use effective relationship management, coordination of services, resource management, education, member advocacy, and related interventions to:
• Promote improved quality of care and/or life
• Prevent hospitalization when possible and appropriate
• Provide for continuity of care
• Ensure appropriate levels of care are received by members
• Maintain knowledge of UM Decision Criteria Hierarchy by health plan and line of business.
• Maintain accurate documentation and records of all communications and interventions with members, member representatives, and providers.
• Identify complex authorization requests and appropriately refer to Case Management personnel.
• Communicate and collaborate with Outpatient UM Coordinators to collect member information/medical records that supports and justifies decisions regarding preauthorization requests.
• Work effectively with all other sub team members within Outpatient UM
• Maintain prompt and open communication with the Denial team to meet tight turnaround time (usually within 24-hours of initial request).

Minimum Education and Experience Qualification Requirements:

• Current California RN or LVN license - Employee can reside anywhere BUT must hold an active and good standing CA nursing license.
• 2+ years of experience in utilization management preferred.
• Proficiency with Microsoft Office Programs; primarily Word and Excel.
• EZ-CAP® knowledge is a plus.

Schedule/ Shift: M-F, 8am-5pm (could potentially be some flexibility here)

Benefits:

• PTO (Paid Time Off): Based on employee tenure, ranges from 15-25 days off per year.
• Holiday Pay: Receive holiday pay for all federal holidays after completing 90th day of employment; 7 paid federal holidays, 3 additional floating holidays.
• Health Benefits / Dental / Vision: Great low-cost group rates for employees! 100% company group paid employee premiums for HMO plan.
• 401k: Competitive company match of the employee's salary.
• Life & Supplemental Insurance
• Employee Assistance Program (EAP)

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.

About Medix?

Medix is dedicated to positively impacting lives every day. Since 2001, we have made it our mission to be the leading provider of workforce solutions for clients and candidates across the Healthcare, Scientific, and Information Technology industries.
Our dedicated recruiters are here to help you find and secure just the right opportunity. We take the time to learn about you, your skills, your interests, and your career goals, and then match you with the jobs and companies that best suit your needs. Whether you are looking for a contract, contract-to-hire, or direct hire positions, we can help you to find the meaningful and gratifying work that you've been looking for.

Join our network of talented professionals!

For 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.