Utilization Management (UM) Nurse - Pre-Service (Must have RN / LVN California Licensure)

Overview of the Role:

Alignment Health is seeking a collaborative and tech savvy RN / LVN utilization management (UM) nurse (must have California license) to join the remote, utilization management, pre-service team. As a UM Nurse, you will review requests for pre-certification for both inpatient and or outpatient services for all plan members. You will also work in collaboration with providers, regional and senior medical directors to assure timely processing of referrals to provide the highest quality medical outcomes that are most cost efficient. If you want to be a part of a collaborative team and growing organization that is committed to improving the lives of seniors - we're looking for YOU!

Schedule: Monday - Friday

8:00am - 5:00pm Pacific Time
9:00am - 6:00pm Mountain Time
10:00am - 7:00pm Central Time
11:00am - 8:00pm Eastern Time

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
• Utilize Milliman Guidelines to assist in determinations of referrals.
• Knowledge of CMS chapter 13
• 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.
• Monitor Fax Folders, System Queues and Email for incoming requests.
• 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.
• Document referral process and any pertinent determination factors within the referral system.
• Review referral denials for appropriate guidelines and language.
• Assist medical director in reviewing and responding to appeals and grievances
• Contact members and maintain documentation of call for expedited requests.
• Assist with UM queue calls relating to UM review and pre-service status when needed.
• Recognize work-related problems and contributes to solutions.
• Meet specific deadlines (responds to various workloads by assigning task priorities according to department policies, standards and needs).
• Maintain confidentiality of information between and among health care professionals.

Required Skills and Experience:

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• Current, active, and unrestricted RN or LVN California licensure required.
• CPHQ or ABQAURP, or Six Sigma certification preferred.
• Minimum Associate’s degree (Bachelor’s degree preferred.)
• Minimum (1) year experience with Medicaid and / or Medicare required.
• Minimum (1) year experience in a medical setting working with IPAs, entering referrals / prior authorizations preferred.
• Minimum (3) years clinical and relevant professional experience.
• Knowledge of Medicare Managed Care Plans
• Knowledge of Medicare and Medicaid coverage benefits, CMS guidelines and regulations required.
• Knowledge of ICD-10, CPT codes, Managed Care Plans, medical terminology (certificate preferred) and referral system (Access Express/Portal/N-coder).
• Experience with the application of UM / clinical criteria (i.e., Milliman, MCG, InterQual, Apollo, CMS National and Local Coverage Determinations, etc.) required.
• Transplant knowledge a plus
• Proficient computer skills
• Experience with Microsoft Office: Word, Excel, Outlook
• Possess a positive attitude
• Collaborative team player
• Excellent interpersonal and relationship management skills
• Bilingual English / Spanish preferred
• Language Skills: Effective written and oral communication skills; Able to establish and maintain a constructive relationship with diverse members, management, employees and vendors.
• Mathematical Skills: Able to perform mathematical calculations and calculate simple statistics correctly.
• Reasoning Skills: 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.
• Problem-Solving Skills: Effective problem solving, organizational and time management skills and ability to work in a fast-paced environment.
• Report Analysis Skills: Comprehend and analyze statistical reports.

Work Environment
The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Essential Physical Functions:

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• While performing the duties of this job, the employee is regularly required to talk or hear.
• The employee regularly is required to stand, walk, sit, use hand to finger, handle or feel objects, tools, or controls; and reach with hands and arms.
• The employee frequently lifts and / or moves up to 10 pounds.
• Specific vision abilities required by this job include close vision and the ability to adjust focus.

PAY RANGE: $74,900 - $100,000 annually
(Depending on skills, experience, and level of licensure)