California Licensed UM Nurse

Job Summary

Seeking a California Licensed UM Nurse for a full-time remote position, who will review prior authorization requests for medical necessity, apply CMS and Milliman Care Guidelines, and collaborate with providers to ensure high-quality care, working Sunday through Thursday during Pacific Time hours.

Key responsibilities:

• Review pre-certification requests for medical necessity and refer to medical director when additional expertise is needed
• Utilize CMS guidelines and Milliman Care Guidelines for referral determinations while maintaining established turnaround times
• Verify eligibility and benefit coverage, and maintain professional rapport with providers and patients to ensure efficient processing of referrals

Required qualifications:

• Minimum of 3 years nursing experience in a clinical setting
• At least 1 year of pre-service UM experience in a managed care environment
• Active, valid, and unrestricted LVN or RN license in California
• Experience with CMS guidelines and Milliman Care Guidelines
• High School Diploma or GED; preferred Associates or Bachelor's degree in Nursing