Remote Utilization Management (UM) LVN Nurse, Must have California Licensure (Long-Term Temp w/ Med Benefits)

Job Number: 6678

Workplace Type: Fully Remote

Position Title: Utilization Management Nurse

External Description:

Overview of the Role:

Alignment Health is seeking a collaborative and tech savvy LVN / LPN utilization management (UM) nurse (must have California license), for a long-term temporary engagement (with medical benefits) to join the remote, utilization management, pre-service team.  As a UM nurse, you will review requests for pre-service 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!

Note: Since Alignment Health is continuing to expand, there is a possibility the engagement could possibly extend and / or convert depending on budget, business need, and individual performance.

Schedule: Monday - Friday (Please review respective time zone below)

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

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.
• Identify appropriate benefits and eligibility for request treatment and / or procedure.
• Review referral denials for appropriate guidelines and language.
• Refer 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.
• Document retrospective review of unauthorized claims / services for payment based upon reasonable criteria.
• Maintain confidentiality of information between and among health care professionals.

Required Skills and Experience:

• Unrestricted LVN / LPN California licensure required.
• Minimum 2 years’ experience with prior-authorization in managed care and utilization management required.
• Minimum 3 years' clinical experience and relevant professional experience required.
• Experience with the application of clinical criteria (i.e., Milliman, MCG, InterQual, Apollo, CMS National and Local Coverage Determinations, etc.) required.
• Strong knowledge of Medicare and Medicaid coverage benefits, CMS guidelines and regulations required.
• Strong computer proficiency in Microsoft Outlook, Word and Excel
• Excellent written and verbal communication skills.
• Collaborative team-player.
• Bilingual English / Spanish preferred.

Pay Rate: $35.19  - $46.65 hourly

City: Remote - CA

State: California

Location City: Remote - CA

Location State: California

Community / Marketing Title: Remote Utilization Management (UM) LVN Nurse, Must have California Licensure (Long-Term Temp w/ Med Benefits)

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].