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

Alignment Health

7d•$77,905 - $116,858•Remote

About The Position

Alignment Health is breaking the mold in conventional health care, committed to serving seniors and those who need it most: the chronically ill and frail. It takes an entire team of passionate and caring people, united in our mission to put the senior first. We have built a team of talented and experienced people who are passionate about transforming the lives of the seniors we serve. In this fast-growing company, you will find ample room for growth and innovation alongside the Alignment Health community. Working at Alignment Health provides an opportunity to do work that really matters, not only changing lives but saving them. Together. 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. Schedule: - Monday – Friday, 8:00 AM – 5:00 PM Pacific Time (must be able to consistently work these hours) - Candidates must reside within Pacific, Mountain, or Central time zones to align with business hours. - Weekend rotation: approximately 1 weekend day every 5–6 weeks (4–8 hour shift between 8:00 AM – 5:00 PM Pacific Time)

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)
Required: 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.

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
Comprehend and analyze statistical reports.

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.