Utilization Management Nurse, RN
About Altais:
At Altais, we’re on a mission to improve the healthcare experience for everyone—starting with the people who deliver it. We believe physicians should spend more time with patients and less time on administrative tasks. Through smarter technology, purpose-built tools, and a team-based model of care, we help doctors do what they do best: care for people.
Altais includes a network of physician-led organizations across California, including Brown & Toland Physicians, Altais Medical Group Riverside, and Family Care Specialists. Together, we’re building a stronger, more connected healthcare system.
About the Role
Are you looking to join a fast-growing, dynamic team?
We’re a collaborative, purpose-driven group that’s passionate about transforming healthcare from the inside out. At Altais, we support one another, adapt quickly, and work with integrity as we build a better experience for physicians and their patients.
As a Utilization Management RN,you'llwork closely with our Ambulatory and Concurrent Care, Network Management, Quality Improvement, and Practice Success teams.Your responsibilities include driving efficient authorization processes, navigating insurance requirements with precision and advocacy.We seek individuals with a strong commitment to patient-centered care and a passion for promoting health and wellness.
You will focus on:
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Interface with external agencies and representativesrelativeto theutilizationmanagement process, including health plans, medical providers,vendorsand CMS.
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Perform Utilization Review activities prospectively or post-service (retrospective) for elective/urgent hospital admissions and outpatient services as specified on the Prior Authorization List with complete andtimelyreports to members, providers and health plans as requested.
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Assistmedical directors with benefit interpretation, obtainadditionalmedical necessity information and research issues. Be available for case discussion as needed.
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Works closely with physicians, other healthcare and service providers, health plan representatives, care managementstaffand partners with UM Coordinators to provide medical management for incoming authorization requests and specialist referrals using nationally recognized guidelines todeterminemedical necessity.
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Review the authorization request and medical information provided by the requesting provider for medical necessity and appropriateness, comparing information to current medical care criteria by health plan and as specified by BTP, CMS, CDC, NCQA and DMHC requirements.
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Review all cases against the division offinancial responsibility(DOFR), Health Plan AncillaryGridsand BTP Ancillary lists to ensureappropriate vendorsareutilizedfor payment of services.
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Formulateappropriate denialletter languagein accordance withIndustry Collaboration effort (ICE)and health plan requirements
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Ensure accuracy of case data in Tapestry including ICD-10,CPTand HCPC codes
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Participate in the annual inter-rater review to evaluate consistency of decision making with in the nursing staff Support Inpatient CareManagement, Network Management, Claims, Customer Service, Quality Improvement and Physician Services staff by offering benefit interpretation, understanding of UM policies and procedures and the application of guidelines in the process of decision making.
The Skills, Experience & Education You Bring
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RN-Registered Nurse of California Licensurerequired.
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Awareness of healthcare reimbursement systems: HMO, PPO, PPS, CMA, all value-based reimbursement models, and alternative payment systems preferred.
- Prior MSO experience preferred.
- 2 years recent relevant experience.
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Recent MCG or InterQual experience highly desired.
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Experience with ICD-9, CPT and HCPCS codes preferred
The Base Salary for this position is $44.63 - $53.55/hr
In addition, we provide a competitive compensation package that recognizes your experience, credentials, and e