Utilization Management Nurse, RN

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🏄 California – Remote

🏄 California – Remote

💵 $44 - $53 / hour

⏰ Full Time

🟢 Junior

🟡 Mid-level

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Altais

WebsiteLinkedInAll Job Openings

201 - 500 employees

Founded 2019

🏥 Healthcare

👥 B2C

🧘 Wellness

Healthcare • B2C • Wellness

Altais is a California-based healthcare provider network that unifies multiple medical brands to offer coordinated primary care, urgent care, specialty services, hospitals and labs, and mental and senior health across Northern and Southern California. The organization supports physicians and care teams with technology-enabled patient portals and value-based care partnerships, serving patients directly while also working with providers and partners to improve access, affordability, and care coordination.

📋 Description

• Interface with external agencies and representatives involved in utilization management, including health plans, medical providers, vendors, and CMS • Perform prospective and retrospective utilization reviews for elective and urgent hospital admissions and outpatient services on the Prior Authorization List • Prepare complete and timely reports for members, providers, and health plans • Assist medical directors with benefit interpretation, obtaining medical necessity information, and researching issues • Participate in case discussions as needed • Manage incoming authorization requests and specialist referrals with physicians, healthcare providers, health plan representatives, care management staff, and UM Coordinators • Apply nationally recognized guidelines to determine medical necessity • Review authorization requests and medical information for medical necessity and appropriateness against health plan criteria and BTP, CMS, CDC, NCQA, and DMHC requirements • Review cases against DOFR, Health Plan Ancillary Grids, and BTP Ancillary lists to ensure appropriate vendors are used • Formulate denial letter language according to ICE and health plan requirements • Maintain accurate case data in Tapestry, including ICD-10, CPT, and HCPC codes • Participate in the annual inter-rater review of nursing decision-making consistency • Support Inpatient Care Management, Network Management, Claims, Customer Service, Quality Improvement, and Physician Services staff with benefit interpretation, UM policies and procedures, and guideline application

🎯 Requirements

• RN-Registered Nurse of California Licensure required • 2 years recent relevant experience • Awareness of healthcare reimbursement systems including HMO, PPO, PPS, CMA, value-based reimbursement models, and alternative payment systems preferred • Prior MSO experience preferred • Recent MCG or InterQual experience highly desired • Experience with ICD-9, CPT, and HCPCS codes preferred • External hires must pass a background check/drug screen • Commitment to patient-centered care and promoting health and wellness

🏖️ Benefits

• Excellent medical, vision, and dental coverage • 401k savings plan with a company match • Flexible time off • 9 Paid Holidays • Annual bonus program eligibility • Competitive compensation package • Background check/drug screen for external hires