Job description

About Us

All Care To You is a Management Service Organization providing our clients with healthcare administrative support. We provide services to Independent Physician Associations, TPAs, and Fiscal Intermediary clients. ACTY is a modern growing company which encourages diverse prospective. We celebrate curiosity, initiative, drive and a passion for making a difference. We support a culture focused on teamwork, support, and inclusion. We offer a flexible work environment and schedules with work from home options. ACTY offers 100% employer paid medical, vision, dental, and life coverage for our employees. We also offer paid holiday, sick time, and vacation time. Additional employee paid coverage options available.

Job purpose

The position of Care Management Nurse reports to the Director of Care Management. The position of UM Nurse is part of the Case Management team and is responsible for the clinical, quality, and patient outcomes. This position is expected to implement the effectiveness and best practices of Utilization Review and will provide high quality medical review by appropriately applying the State, Federal, health plan and or clinical guidelines used to determine medical necessity.

Duties and responsibilities

• Comply with UM policies and procedures. Annual review of UM policies.
• Review & screen incoming service referral requests for medical necessity.
• Applies the appropriate clinical criteria/guideline, policy, EOC/benefit policy and clinical judgment to render coverage determination/recommendation for the review process.
• Knowledge of health plan DOFRs and contracts and how they apply to the review process.
• Review member' utilization and claim history when processing a referral.
• Apply Correct Coding Initiative as per clinical criteria.
• Clinical documentation, specific criteria, and record attachment for referral prior to sending to the Medical Director for review.
• Maintain quality reviews while meeting the established TATs for Urgent, Routines and Retro requests.
• Daily production standard is a minimum of 50-90 referrals/day depending on complexity with accuracy & quality.
• Makes approval determinations when request meets appropriateness, medical necessity and benefit criteria.
• Utilizes clinical experience and skills in a collaborative process to assess, plan, implement, coordinate, monitor and evaluate options to facilitate appropriate healthcare services that meets criteria and can be authorized by a nurse level reviewer.
• Act as clinical resources to all departments.
• Communicates with health plans, providers, members and other parties to facilitate member care treatment plan.
• Identifies opportunities to promote quality effectiveness of Healthcare Services and benefit utilization or appropriate services to our patients.
• Review claim and referral appeals and forward them to the Medical Director when appropriate.
• Work closely with Claims Manager on overlapping issues such as rates and procedures and CPT codes for new procedures.
• Attend to provider and interdepartmental calls in accordance with exceptional customer service.
• Ability to keep high level of confidence and discretion when dealing with sensitive matters relating to providers, and members. Always maintains strictest confidentiality.
• Other duties as needed.

Qualifications

• Valid California Registered Nurse 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. Medi-Cal, Commercial and Medicare contracts and benefit interpretation is preferred.
• Five years+ clinical experience.
• Prefer of two (2) years+ experience in an HMO/IPA/Managed care setting is preferred and recommended.
• Able to work 8:30 - 5 PM Pacific Standard Time
• 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.
• Process oriented.
• Strong ability to multi-task, project management, and work in a fast-paced environment
• Strong ability in problem-solving
• Ability to self-manage, strong time management skills
• Ability to work in an extremely confidential environment
• Strong written and verbal communication skills

Education and Additional Requirements

• Valid California Registered Nurse license.

Working conditions

• This job may require flexible work hours due to the nature of the responsibilities
• Candidate must be comfortable with ambiguity and open to working in a collaborate environment

Job Type: Full-time

Pay: $95,000.00 - $115,000.00 per year

Benefits:

• 401(k)
• Dental insurance
• Flexible spending account
• Health insurance
• Life insurance
• Paid time off
• Vision insurance

Weekly schedule:

• Monday to Friday

Application Question(s):

• Have you worked in an HMO/IPA/Managed care setting?
• Do you have a current, valid California Registered Nurse license?

Experience:

• Case management: 2 years (Preferred)

Work Location: Remote

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