Outpatient Review Nurse

Job not on LinkedIn

🔥 13 hours ago

🏄 California, Texas – Remote

🏄 California – Remote 🤠 Texas – Remote

💵 $70k - $120k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

👻 Ghost score 0%

What it means: how likely this posting is sitting open without active hiring.How to read it: 60% or higher means we think this is a ghost. Lower scores are less of a worry.How we score it: age, reposts, open roles vs team size, how fast jobs close, and whether pay is listed.Fine print: an estimate from public data, not a judgment of the company. Real jobs can score high, so treat it as a hint, not a fact.

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All Care To You

WebsiteLinkedInAll Job Openings

51 - 200 employees

Founded 2018

🏥 Healthcare

⚕️ Healthcare Insurance

💼 Consulting

Healthcare • Healthcare Insurance • Consulting

All Care To You is a Management Service Organization (MSO) dedicated to fostering a collaborative work environment grounded in knowledge, trust, growth, and respect. The company primarily operates within the hospitals and healthcare sector, offering a range of services that support healthcare providers and enhance patient care.

📋 Description

• Review authorization requests for medical necessity and determine which requests need Medical Director review • Obtain sufficient medical documentation for informed review • Process all requests within established time frames • Document all process steps in the authorization system notes • Utilize CMS and Health Plan Hierarchy criteria • Prepare clinical documentation, specific criteria, and record attachments for Medical Director referral • Conduct retrospective reviews of services to determine medical necessity • Refer cases to the Medical Director when requests may not meet medical necessity criteria • Process denials within established timeframes • Write denial letters meeting CMS and Health Plan requirements • Apply clinical criteria, guidelines, policies, benefit policies, and clinical judgment to render coverage determinations or recommendations • Review member utilization and claim history when processing referrals • Maintain quality reviews while meeting turnaround times for urgent, routine, and retrospective requests • Maintain an Interrater Reliability Rate of at least 95% • Meet a daily production standard of 50–90 referrals per day depending on complexity, accuracy, and quality • Make approval determinations when requests meet appropriateness, medical necessity, and benefit criteria • Assess, plan, implement, coordinate, monitor, and evaluate healthcare service options • Act as a clinical resource to all departments • Communicate with health plans, providers, members, and other parties to facilitate member care treatment plans • Participate in team training • Comply with UM policies and procedures and attend provider and interdepartmental calls • Maintain strict confidentiality when handling sensitive provider and member matters • Perform other duties as needed

🎯 Requirements

• A valid CA and Texas/Multi State Registered Nurse license or Licensed Vocational Nurse • Current unrestricted CA and Texas/Multi State RN or LVN license • CM and/or UM training and/or certification • Knowledge of CM standards, UM standards, Clinical Standards of Care, NCQA requirements, CMS guidelines, Milliman guidelines, and InterQual guidelines • Knowledge of Medi-Cal, Commercial and Medicare contracts and benefit interpretation preferred • Five years+ clinical experience • Two years+ experience in an HMO / IPA / Managed care setting preferred and recommended • Must be available to work weekends and holidays as business needs require • Ability to work independently with minimal supervision, exercising judgment and initiative • Ability to manage multiple tasks with effective prioritization • Proficiency using Outlook, Microsoft Teams, Zoom, Microsoft Office including Word and Excel, and Adobe • Detail oriented and highly organized • Strong ability to multi-task, project management, and work in a fast-paced environment • Strong problem-solving ability • Strong self-management and time-management skills • Ability to work in an extremely confidential environment • Strong written and verbal communication skills

🏖️ Benefits

• 100% employer paid medical, vision, dental, and life coverage • Additional employee paid coverage options • Paid holidays • Birthday off • Unlimited PTO • 401k plan • Fully remote work environment • Flexible work environment and schedules