UM Nurse, LVN (Temporary) *Must be licensed in CA, Must have Pre-Authorization Experience*

Job Number: 6535

Workplace Type: Fully Remote

Position Title: Utilization Management Nurse

External Description:

Are you licensed as an LVN in California? Do you have 2 years of Pre-authorization experience in a managed care setting? If so, we want to speak with you!

Overview of the Role:

The UM Nurse is responsible for reviewing requests for Pre-service for both inpatient and or outpatient services for all plan members. The UM Nurse 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.

Responsibilities:

• Review authorization request within specified timeframes.
• Review authorization request for out-of-network providers.
• Initiate single service agreements (SSA) when services required are not available in network.
• Utilize appropriate resources to guide review decisions and document decisions clearly and concisely.
• Identifies appropriate benefits and eligibility for request treatment and/or procedure.
• Review referral denials for appropriate guidelines and language.
• Refers appropriate prior authorization requests to Medical Directors.
• Assist Medical Directors 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 contribute to solutions.
• Determine the appropriateness of denial, and draft denial language to ensure consistent, nationally recognized UM criteria and appropriate use of denial language.
• Assist in the prospective review process by screening the referrals for adequate information for medical necessity and appropriateness of service and care.
• Documentation of retrospective review of unauthorized claims/services for payment based upon reasonable criteria.
• Maintain confidentiality of information between and among health care professionals.
• Other duties as assigned by UM Manager.

Requirements:

• Unrestricted LVN/LPN licensure required with 3 years of clinical experience and relevant professional experience.
• Strong knowledge of Medicare and Medicaid coverage benefits, CMS guidelines and regulations
• A minimum of 2 years’ experience in managed care and utilization management
• Computer literate with proficiency in Microsoft Outlook, Word and Excel
• Bilingual (English/Spanish) preferred.
• Experience with the application of clinical criteria (i.e., Milliman, InterQual, Apollo, CMS National and Local Coverage Determinations, etc.) preferred.

City: Remote - CA

State: California

Location City: Remote - CA

Location State: California

Community / Marketing Title: UM Nurse, LVN (Temporary) *Must be licensed in CA, Must have Pre-Authorization Experience*

Company Profile:

By leveraging our world-class technology platform, innovative care delivery models, deep physician partnerships and our serving heart culture, Alignment Health is revolutionizing health care for seniors! From member experience professionals and clinicians, to data scientists and operations leaders, we have built a talented and passionate team that is deeply committed to our mission of transforming health care for the seniors we serve. Ready to join us?

At Alignment, delivering exceptional care to seniors starts with ensuring an exceptional experience for our over 1,300 employees. At the center of our employee experience is a culture where employees at all levels and across all teams are encouraged to share their unique ideas and perspectives. After all, when you can bring your authentic self to work, whether that’s in a clinical setting, our corporate office or a home office, creativity and innovation flourish! Another important part of the Alignment culture is a belief in continuous learning and growth. As a result, in this fast-growing company, you will find ample support to grow your skills and your career – with us.

EEO Employer Verbiage:

 

Please note: All clinical positions are contingent upon successful engagement with Alignment Health’s COVID-19 Vaccination program (fully vaccinated with documented proof or approved exception/deferral).

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.

*DISCLAIMER: Please beware of recruitment phishing scams affecting Alignment Health and other employers where individuals receive fraudulent employment-related offers in exchange for money or other sensitive personal information. Please be advised that Alignment Health and its subsidiaries will never ask you for a credit card, send you a check, or ask you for any type of payment as part of consideration for employment with our company. If you feel that you have been the victim of a scam such as this, please report the incident to the Federal Trade Commission at https://reportfraud.ftc.gov/#/. If you would like to verify the legitimacy of an email sent by or on behalf of Alignment Health’s talent acquisition team, please email [email protected].