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 (Must live in North Carolina (NC), Must have LVN / RN License in North Carolina) to join the UM team. As a UM Nurse, you will be responsible for reviewing requests for pre-certification for both inpatient and or outpatient services for all plan members. Works 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 are looking for an opportunity to join an expanding company, learn and grow, be part of a collaborative team, and make a positive impact in the lives of seniors - we're looking for YOU!

Other Jobs You May Be Interested In

Remote Data Entry, No Experience, $40/hr, Part-Time
Virtual Assistant, $45/hr, Remote, No Experience, Night Job
Entry-Level Remote Data Entry, $50/hr, Evening Job
Customer Support, No Degree, $40/hr, Remote, Weekend Job
Remote Phone Job, $42/hr, Part-Time, College Student Friendly
Virtual Assistant, $40/hr, Remote, No Degree, Night Job
Part-Time Data Entry, $45/hr, Remote, College Student Friendly
Remote Moderator, No Degree, $50/hr, Evening, Weekend Job
Remote Customer Support, $42/hr, Night Job, No Experience
Live Chat Support, $40/hr, Remote, Entry Level, Part-Time
Virtual Assistant, Remote, $42/hr, Weekend, No Experience
Remote Data Entry, $45/hr, No Degree, Night Shift
Part-Time Customer Support, $40/hr, Remote, College Student
Remote Live Chat, $50/hr, Part-Time, Evening/Night Job
Entry Level Phone Job, $42/hr, Remote, No Degree Required
Weekend Data Entry, $45/hr, Remote, No Experience
Remote Virtual Assistant, $40/hr, Evening, Part-Time Job
Remote Moderator, $42/hr, Part-Time, Weekend, No Degree
Data Entry, $45/hr, Remote, Night Shift, College Student Job
Phone Support, Remote, $50/hr, No Experience, Part-Time
Virtual Assistant, No Experience, $42/hr, Remote, Weekend
Remote Customer Support, $45/hr, Part-Time, College Student
Data Entry, Remote, $40/hr, Night Shift, No Degree
Evening Virtual Assistant, Remote, $45/hr, No Experience
Weekend Customer Support, $42/hr, Remote, College Student
Remote Data Entry, $50/hr, No Experience, Evening/Night Job
Remote Live Chat, $40/hr, Part-Time, No Degree Required
Virtual Assistant, $42/hr, Remote, Weekend, Entry Level
Remote Phone Support, $45/hr, Evening, No Experience Required
Data Entry, No Experience, $50/hr, Remote, College Student
Remote Moderator, $40/hr, Weekend, No Degree, Part-Time
Live Chat Support, Remote, $42/hr, Night Shift, College Student
Phone Job, $50/hr, Remote, No Degree, Part-Time, Weekend
Data Entry, $45/hr, Remote, Evening, No Experience Required
Virtual Assistant, No Experience, $42/hr, Remote, Part-Time
Remote Customer Support, $50/hr, Night Shift, No Degree
Remote Data Entry, $40/hr, College Student Friendly, Part-Time
Live Chat Support, $42/hr, Weekend, Remote, No Degree
Virtual Assistant, Remote, $45/hr, Evening, No Experience
Remote Phone Job, $50/hr, College Student, Night Shift
Remote Moderator, $42/hr, Weekend, No Experience Required
Data Entry, No Degree, $45/hr, Part-Time, Remote Job
Customer Support, $50/hr, Remote, Evening/Night Job, No Degree
Virtual Assistant, $42/hr, Remote, Weekend, No Degree
Remote Live Chat, $45/hr, College Student, No Experience
Remote Data Entry, $40/hr, Part-Time, No Degree Required
Phone Support, $50/hr, Weekend, Remote, No Experience
Virtual Assistant, $42/hr, Evening, Remote, No Degree
Remote Customer Support, $45/hr, No Experience, Part-Time
Data Entry, $50/hr, Night Job, No Degree, Remote
Remote Moderator, $40/hr, College Student Friendly, Part-Time
Virtual Assistant, Remote, $42/hr, Weekend, No Experience
Remote Phone Job, $45/hr, Part-Time, No Degree Required
Customer Support, $50/hr, Night Job, Remote, No Experience
Data Entry, Remote, $42/hr, Evening Job, No Degree
Live Chat Support, $45/hr, Weekend, Remote, College Student
Virtual Assistant, Remote, $50/hr, Part-Time, Night Shift
Data Entry, $40/hr, No Experience, Remote, Weekend Job
Remote Phone Job, $45/hr, No Degree, College Student Friendly
Customer Support, $42/hr, Remote, Evening, No Experience
Virtual Assistant, $50/hr, Weekend, No Degree, Remote
Remote Data Entry, $40/hr, Part-Time, College Student Job
Phone Support, Remote, $42/hr, Evening/Night Shift
Virtual Assistant, No Degree, $45/hr, Remote, Part-Time
Live Chat Support, $50/hr, Remote, No Experience Required
Remote Moderator, $42/hr, College Student, Weekend Job
Data Entry, $45/hr, Remote, Night Job, No Degree
Virtual Assistant, $50/hr, Remote, Part-Time, Evening Job
Remote Customer Support, $42/hr, Weekend, No Experience
Phone Job, $45/hr, Remote, Night Shift, No Degree
Remote Live Chat, $50/hr, College Student, No Experience
Data Entry, $40/hr, Part-Time, Remote, Weekend Job
Virtual Assistant, $42/hr, Remote, No Experience, Evening
Remote Phone Support, $45/hr, Night Job, College Student
Remote Moderator, $50/hr, No Degree, Weekend, Part-Time
Virtual Assistant, $40/hr, Remote, Night Shift, No Experience
Customer Support, $42/hr, Remote, Part-Time, No Degree
Remote Data Entry, $45/hr, Weekend Job, College Student
Phone Support, Remote, $50/hr, No Experience, Night Shift
Virtual Assistant, $42/hr, Evening, Remote, College Student
Live Chat Support, $45/hr, Part-Time, Remote, No Degree
Data Entry, $50/hr, Remote, Evening Job, College Student
Virtual Assistant, $40/hr, Weekend, Remote, No Experience
Remote Phone Job, $42/hr, Night Shift, College Student Friendly
Remote Customer Support, $45/hr, No Degree, Evening Job
Virtual Assistant, $50/hr, Part-Time, Remote, Weekend Job
Data Entry, $40/hr, Evening Job, No Experience, Remote
Remote Live Chat, $42/hr, Weekend, No Degree, Part-Time
Virtual Assistant, $45/hr, No Experience, Remote, Night Job
Phone Job, $50/hr, Remote, Part-Time, College Student
Remote Data Entry, $42/hr, Evening/Night Job, No Experience
Remote Moderator, $45/hr, No Degree, Weekend Job, Part-Time
Live Chat Support, $50/hr, Remote, Night Shift, No Degree
Virtual Assistant, $40/hr, Weekend, College Student, Remote
Remote Phone Job, $42/hr, Part-Time, No Experience Required
Remote Data Entry, $45/hr, No Degree, Weekend, Night Job
Virtual Assistant, $50/hr, Evening, Remote, College Student
Customer Support, $42/hr, Weekend Job, Remote, No Degree
Phone Support, $45/hr, Remote, No Experience, Evening Job
Data Entry, $50/hr, Night Shift, No Degree, Remote Job

GENERAL DUTIES / RESPONSIBILITIES:

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

Experience:

Job Requirements:

Required:

• 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 MCG (Milliman Care Guidelines)
  
  

Education:

• Required: High School Diploma or GED.
• Preferred: Associates or Bachelor's degree in Nursing
  
  

Licensure:

Required:

• Possess current, active and unrestricted LVN and / or RN license in North Carolina (Compact)
• Immediately upon hire, must obtain LVN and / or RN licensure in California (non-compact), Nevada, (Non-compact), Arizona (Compact), and Texas (Compact) which will be reimbursed by company.
  
  

Preferred:

• CPHQ or ABQAURP, or Six Sigma certification
• Medical Terminology Certificate.
  
  

Training:

• Required: None
• Preferred: Medical Terminology. Six Sigma
  
  

Required:

Specialized Skills:

• 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.
• Computer Skills: Word, Excel, Microsoft Outlook
• Language Skills: Effective written and oral communication skills; ability to establish and maintain a constructive relationship with diverse members, management, employees and vendors.
• Mathematical Skills: Ability to perform mathematical calculations and calculate simple statistics correctly.
• Reasoning Skills: Ability 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.
  
  

Preferred:

• Bilingual (English / Spanish)
• Transplant knowledge a plus
  
  

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: $72,452.00 - $108,678.00

Alignment Health is an Equal Opportunity/Affirmative Action Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, age, protected veteran status, gender identity, or sexual orientation.