Utilization Management

Description:

Alignment Health is seeking a remote Utilization Management (UM) Nurse - Pre-service to join the UM team. This role involves reviewing requests for pre-certification for inpatient and outpatient services, collaborating with providers and medical directors to ensure timely processing of referrals for the best medical outcomes at the most cost-efficient rate.

General Duties / Responsibilities:

• Review pre-certification requests for medical necessity and refer to the Medical Director when necessary.

• Utilize CMS guidelines and Milliman Care Guidelines (MCG) for referral determinations.

• Maintain goals for turnaround time (TAT) for referral processing.

• Initiate Single Service Agreements (SSA) when services required are not available in-network.

• Maintain professional rapport with providers, physicians, support staff, and patients for efficient pre-certification referral processing.

• Verify eligibility and benefit coverage for requested services.

• Verify accuracy of ICD-10 and CPT coding in processing pre-certification requests.

• Request medical records and documentation from providers when necessary.

• Assist in reviewing and responding to appeal and grievance cases.

• Maintain documentation of expedited requests.

Minimum Qualifications & Skills:

• 3+ years' nursing experience in a clinical setting.

• 1+ year UM experience with pre-service.

• 1+ year experience in managed care (Medicaid and/or Medicare).

• 1+ year experience applying UM criteria (CMS guidelines, MCG).

• Familiarity with medical terminology, ICD-10, CPT codes, and referral systems.

• Proficiency in Word, Excel, Microsoft Outlook.

Education & Licensure:

• Required: High School Diploma or GED.

• Preferred: Associate's or Bachelor's degree in Nursing.

• Must have active LVN / RN license in North Carolina (Compact), with the ability to obtain additional state licenses (California, Nevada, Arizona, Texas).

Preferred Qualifications:

• CPHQ, ABQAURP, or Six Sigma certification.

• Bilingual (English / Spanish).

• Experience in Transplant knowledge.

Physical Demands:

• Regularly required to talk or hear.

• Frequently lifts and/or moves up to 10 pounds.

Benefits:

• Competitive compensation package.

• Equal Opportunity/Affirmative Action Employer.