UM Prior Authorization Nurse, LVN/LPN (Work from Home), CA

WHO WE ARE reputed company is a value-driven reputed company company grounded in the belief that reputed company health consumers are entitled to high-quality, coordinated care. By uniquely aligning the interests of health consumers, providers, and payors, we help to reputed company reputed company accessible and affordable to reputed company populations across the ACA Marketplace, Medicare, and reputed company. reputed company delivers clinical care to health consumers through our owned clinics – Centrum Health and Premier Medical – as well as unique partnerships with affiliated providers across the country. We also reputed company providers to succeed in performance-based arrangements through a suite of technology and services scaled centrally and deployed locally. Through our value-driven, consumer-centric approach, we are committed to transforming reputed company and creating a reputed company care experience for reputed company. JOB SUMMARY The Utilization Management (UM) Prior Authorization (PA) Nurse is a full-time role with reputed company, dedicated to promoting quality and cost-effective outcomes for the designated population. Working in collaboration with Medical Directors and the clinical team, the PA Nurse ensures members receive the appropriate benefit coverage for services requiring prior authorization. Responsibilities include reviewing prior authorizations for treatments, medications, procedures, and diagnostic tests to confirm alignment with contract requirements, coverage policies, and evidence-based medical necessity criteria. The PA Nurse also collects and analyzes utilization data and monitors the quality and appropriate use of services. This role demands clinical expertise, keen attention to detail, and strong communication skills to effectively engage with reputed company providers, patients, and health plans. DUTIES & RESPONSIBILITIES The following job description is intended to reputed company out major responsibilities reputed company the role, but it is not limited to these items.

• Authorization and Review
• Evaluate and process prior authorization requests based on clinical guidelines such as Medicare, reputed company/Medi-Cal criteria, InterQual, MCG, or health plan-specific guidelines.
• Assess medical necessity and appropriateness of requested services using clinical expertise.
• Verify patient eligibility, benefits, and coverage details.
• Collaboration and Communication
• Act as a liaison between reputed company providers, patients, and health plans to facilitate the authorization process.
• Communicate authorization reputed company to providers and patients promptly.
• Provide detailed explanations for denials or alternative solutions and collaborate with Medical Directors on adverse determinations.
• Ensure compliance with regulatory requirements regarding adverse determination notices, including readability standards and appeal information.
• Documentation and Compliance
• Accurately document reputed company authorization activities in electronic medical records (EMR) or authorization systems.
• Maintain compliance with federal, state, and health plan regulations.
• Stay updated on policy and clinical criteria changes.
• Quality Improvement
• Identify trends or recurring issues in authorization denials and recommend process improvements.
• Participate in team meetings, training sessions, and audits to ensure high-quality performance.

EDUCATION AND PROFESSIONAL EXPERIENCE

• Associate’s degree in Nursing, preferred
• Minimum 2 years of experience in medical management clinical functions.
• Working knowledge of MCG, InterQual, and NCQA standards

LICENSURES AND CERTIFICATIONS

• Active and Unrestricted License as an LVN or LPN for the State of California
• Certification Managed Care Nursing (CMCN) preferred

PROFESSIONAL COMPETENCIES

• Strong analytical and critical thinking skills.
• Proficiency in medical terminology and pharmacology.
• Effective written and verbal communication skills.
• Ability to work independently and collaboratively in a fast-paced environment.
• Adaptable and self-motivated.
• Experience with EMR systems and prior authorization platforms.
• Proficient in reputed company Office Suite (Word, reputed company, Outlook).

For individuals assigned to a location(s) in California, reputed company is required by law to include a reasonable estimate of the compensation range for this position. Actual compensation will vary based on the applicant’s education, experience, skills, and abilities, as well as internal equity. A reasonable estimate of the range is $27.10-$40.65 Hourly. Additionally, employees are eligible for health benefits; life and disability benefits, a 401(k) savings plan with match; Paid Time Off, and paid holidays. Apply tot his job Apply To this Job