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Job description
Description The UM Denial Nurse Reviewer supports high-quality, cost-effective care by applying clinical knowledge, policies, and regulatory guidelines to the review and processing of adverse organization determinations. This role reviews denials for appropriate clinical documentation and criteria, provides clinical guidance on denial cases, and ensures written notifications are accurate, understandable, timely, and compliant with policies and applicable regulatory requirements.
Key Responsibilities:
Review and process denials for appropriate clinical documentation, clinical criteria/guidelines, benefit policies, and regulatory compliance.
Apply clinical knowledge and the appropriate clinical review hierarchy when evaluating denial cases and written notifications.
Collaborate with Denial Coordinators, Prior Authorization teams, Medical Directors, and department leadership to clarify cases and support appropriate denial determinations.
Monitor denial processing and turnaround times to ensure regulatory standards and guidelines are met.
Review denial letters for clear, understandable language and compliance with applicable requirements.
Identify trends in denial types and outcomes and support process improvement initiatives.
Develop and analyze denial activity and outcome reports to identify opportunities for improvement.
Salary Range: $65,800 - $130,800/Annually
Qualifications We're seeking an exceptionally gifted, self-motivated leader with:
Current CA LVN licensure required
Two or more years of utilization review/utilization management experience in an HMO, MSO, IPA, or health plan environment
Previous clinical experience
Experience drafting and issuing compliant adverse organization determinations
In-depth knowledge of health plan, DMHC, CMS, HIPPA, and NCQA requirements
Expertise in abstracting and interpreting medical information from patient records
Strong communication, interpersonal, analytical, problem-solving, organizational, and prioritizing skills
Thorough understanding of the Hierarchy of Clinical Criteria
Experience with Flesch-Kincaid readability scoring
Knowledge of the appeals process
Experience with audit preparation
Basic computer skills
Who can apply
Review the original listing for work authorization, qualifications and employer requirements.