Utilization Management (UM) – Pre-Service (Remote | California RN / LVN | Pacific Time Schedule)

About the position Alignment Health is seeking a remote Utilization Management (UM) Nurse – Pre-Service (LVN or RN, active California license required) to join our growing UM team. In this role, you’ll review prior authorization requests for medical necessity across inpatient and outpatient services, applying CMS guidelines and Milliman Care Guidelines (MCG) to support timely, accurate determinations. You’ll partner closely with providers and medical directors to ensure members receive high-quality, cost-effective care. This is a fast-paced, production-driven role ideal for nurses with recent pre-service UM experience in a managed care setting who are comfortable managing multiple cases, meeting turnaround time expectations, and collaborating cross-functionally in a fully remote environment.

Responsibilities

• Review pre-certification requests for medical necessity and refer to medical director any referral that requires additional expertise.
• Utilize CMS guidelines (LCD, NCD) to assist in determinations of referrals and utilize Milliman Care Guidelines (MCG) to assist in determinations of referrals.
• Maintain goals for established turn-around time (TAT) for referral processing.
• Initiate single service agreements (SSA) when services required are not available in network.
• Maintain a professional rapport with providers, physicians, support staff and patients in order to process pre-certification referrals as efficiently as possible.
• Verify eligibility and / or benefit coverage for requested services.
• Verify accuracy of ICD 10 and CPT coding in processing pre-certification requests.
• Contact requesting provider and request medical records, orders, and / or necessary documentation in order to process related pre-service requests / authorizations when necessary.
• Review referral denials for appropriate guidelines and language.
• Assist medical directors in reviewing and responding to appeals and Grievances.
• Contact members and maintain documentation of call for expedited requests.
• Other duties as assigned.

Requirements

• Minimum (3) years' nursing experience in clinical setting.
• Minimum (1) year experience UM experience with pre-service.
• Minimum (1) year experience with managed care (Medicaid and / or Medicare).
• Minimum 1 year of experience with the application of UM criteria (i.e., CMS National and Local Coverage Determinations, etc.)
• Minimum (1) year experience in a medical setting working with IPAs, entering referrals / prior authorizations preferred.
• Minimum (1) Experience with the application of clinical criteria, specifically Milliman Care Guidelines (MCG).
• High School Diploma or GED.
• Must have and maintain an active, valid, and unrestricted LVN or RN license in California (Non-Compact).
• Immediately upon hire, must be willing to obtain LVN and / or RN licensure in Nevada, (Non-compact), Arizona (Compact), North Carolina (Compact), and Texas (Compact) which will be reimbursed by company.
• Knowledge of ICD-10, CPT codes, managed care plans, medical terminology and referral system (Access Express / Portal / N-coder).
• Knowledgeable with CMS (Chapter 13) guidelines and regulations.
• Word, Excel, Microsoft Outlook.
• Effective written and verbal communication skills; able to establish and maintain a constructive relationship with diverse members, management, employees and vendors.
• Able to perform mathematical calculations and calculate simple statistics correctly.
• Able to prioritize multiple tasks; advanced problem-solving; ability to use advanced reasoning to define problems, collect data, establish facts, draw valid conclusions, and design, implement and manage appropriate resolution.
• Effective problem solving, organizational and time management skills and ability to work in a fast-paced environment.
• Comprehend and analyze statistical reports.

Nice-to-haves

• Associates or Bachelor's degree in Nursing.
• CPHQ or ABQAURP, or Six Sigma certification.
• Medical Terminology Certificate.
• Medical Terminology.
• Six Sigma.
• Bilingual English and Spanish.
• Transplant knowledge a plus.

Benefits

• Reimbursed licensure in Nevada, Arizona, North Carolina, and Texas.

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