Remote UM Nurse – Pre-Service (Must have North Carolina LVN / RN License)

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 (Must have North Carolina LVN / RN License) 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!

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

Requirements
• Minimum (3) years’ nursing experience in clinical setting.
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• Minimum (1) year experience UM experience with pre-service.
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• Minimum (1) year experience with managed care (Medicaid and / or Medicare).
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• Minimum 1 year of experience with the application of UM criteria (i.e., CMS National and Local Coverage Determinations, etc.)
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• Minimum (1) year experience in a medical setting working with IPAs, entering referrals / prior authorizations preferred.
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• Minimum (1) Experience with the application of clinical criteria, specifically MCG (Milliman Care Guidelines).
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• Possess current, active and unrestricted LVN and / or RN license in North Carolina (Compact).

Nice-to-haves
• Associates or Bachelor’s degree in Nursing.
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• CPHQ or ABQAURP, or Six Sigma certification.
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• Medical Terminology Certificate.
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• Bilingual (English / Spanish).
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• Transplant knowledge a plus.

Benefits
• Pay Range: $77,905.00 – $116,858.00