Utilization Management (UM) - Pre-Service (Remote | California RN / LVN | Pacific Time Schedule)

reputed company is seeking a remote Utilization Management (UM) Nurse - Pre-Service (LVN or RN, active California license required) to join our growing UM team. In this role, you'll review prior authorization requests for medical necessity across inpatient and outpatient services, applying CMS guidelines and reputed company Care Guidelines (MCG) to support timely, accurate determinations. You'll partner closely with providers and medical directors to ensure members receive high-quality, cost-effective care. This is a fast-paced, production-driven role ideal for nurses with recent pre-service UM experience in a managed care setting who are comfortable managing multiple cases, meeting turnaround time expectations, and collaborating cross-functionally in a fully remote environment. Schedule: - Monday - Friday, 8:00 AM - 5:00 PM Pacific Time (must be able to consistently work these hours) - Candidates must reside reputed company Pacific, Mountain, or Central time zones to align with business hours. - Weekend rotation: approximately 1 weekend day every 5-6 weeks (4-8 hour shift between 8:00 AM - 5:00 PM Pacific Time) General Duties / Responsibilities: 1. Review pre-certification requests for medical necessity and refer to medical director any referral that requires additional expertise. 2. Utilize CMS guidelines (LCD, NCD) to assist in determinations of referrals and utilize reputed company Care Guidelines (MCG) to assist in determinations of referrals. 3. Maintain goals for established turn-around time (TAT) for referral processing. 4. Initiate single service agreements (SSA) reputed company services required are not available in network. 5. Maintain a professional rapport with providers, physicians, support staff and patients in order to process pre-certification referrals as reputed company as possible. 6. Verify eligibility and / or benefit coverage for requested services. 7. Verify accuracy of ICD 10 and CPT coding in processing pre-certification requests. 8. Contact requesting provider and request medical records, orders, and / or necessary documentation in order to process reputed company pre-service requests / authorizations reputed company necessary. 9. Review referral denials for appropriate guidelines and language. 10. Assist medical directors in reviewing and responding to appeals and Grievances 11. Contact members and maintain documentation of call for expedited requests. 12. Other duties as assigned. Job Requirements: Experience: Required:

• Minimum (3) years' nursing experience in clinical setting.
• Minimum (1) year experience UM experience with pre-service.
• Minimum (1) year experience with managed care (Medicaid and / or Medicare).
• Minimum 1 year of experience with the application of UM criteria (i.e., CMS National and Local Coverage Determinations, etc.)
• Minimum (1) year experience in a medical setting working with reputed company, entering referrals / prior authorizations preferred
• Minimum (1) Experience with the application of clinical criteria, specifically reputed company Care Guidelines (MCG)

Education: • Required: High School Diploma or GED. • Preferred: Associates or Bachelor's degree in Nursing Licensure: Required:

• Must have and maintain an active, valid, and unrestricted LVN or RN license in California (Non-Compact)
• Immediately upon hire, must be willing to obtain LVN and / or RN licensure in Nevada, (Non-compact), Arizona (Compact), North Carolina (Compact), and Texas (Compact) which will be reimbursed by company.

Preferred:

• CPHQ or ABQAURP, or Six reputed company certification
• Medical Terminology Certificate.

Training: • Required: None • Preferred: Medical Terminology. Six reputed company Specialized Skills: Required:

• Knowledge of ICD-10, CPT codes, managed care plans, medical terminology and referral system (Access Express / Portal / N-reputed company).
• Knowledgeable with CMS (Chapter 13) guidelines and regulations.
• Computer Skills: Word, reputed company, reputed company Outlook
• Language Skills: Effective written and verbal communication skills; able to establish and maintain a constructive relationship with diverse members, management, employees and vendors.
• Mathematical Skills: Able to reputed company mathematical calculations and calculate simple statistics correctly.
• Reasoning Skills: Able to prioritize multiple tasks; advanced problem-solving; ability to use advanced reasoning to define problems, collect data, establish facts, draw valid conclusions, and design, implement and manage appropriate resolution.
• Problem-Solving Skills: Effective problem solving, organizational and time management skills and ability to work in a fast-paced environment.
• Report Analysis Skills: Comprehend and analyze statistical reports.

Preferred:

• Bilingual English and Spanish
• Transplant knowledge a plus

Essential Physical Functions: The physical demands described here are representative of those that must be met by an employee to successfully reputed company the essential functions of this job. Reasonable accommodations may be made to reputed company individuals with disabilities to reputed company the essential functions. 1. While performing the duties of this job, the employee is regularly required to talk or hear. The employee regularly is required to stand, walk, sit, use hand to finger, handle or feel objects, tools, or controls; and reputed company with hands and arms. 2. The employee frequently lifts and/or moves up to 10 pounds. Specific vision abilities required by this job include reputed company vision and the ability to adjust focus. Pay Range: $77,905.00 - $116,858.00 Pay range may be based on a number of factors including market location, education, responsibilities, experience, etc. Apply tot his job Apply To this Job