UM Nurse, Pre-service – California RN/LVN License Required

🔥 2 hours ago

🏄 California – Remote

🏄 California – Remote

💵 $77.9k - $116.9k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

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Alignment Health

WebsiteLinkedInAll Job Openings

501 - 1000 employees

Founded 2013

⚕️ Healthcare Insurance

💰 $135M Series C on 2020-03

Healthcare Insurance • Insurance • Healthcare

Alignment Health is dedicated to providing comprehensive care for Medicare members, emphasizing the needs of seniors, the chronically ill, and those who are frail. With a mission to transform senior healthcare, Alignment Health leverages a tailored care model and advanced technology to deliver high-quality, low-cost healthcare services. Their 24/7 concierge care team collaborates with trusted local providers to ensure that every member receives personalized care, reflecting the company's commitment to treating all members as valued family members.

📋 Description

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

🎯 Requirements

• 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 Milliman Care Guidelines (MCG) • Must have and maintain an active, valid, and unrestricted LVN or RN license in California (Non-Compact). • Immediately upon hire, must be willing to obtain LVN and / or RN licensure in Nevada, (Non-compact), Arizona (Compact), North Carolina (Compact), and Texas (Compact) which will be reimbursed by company. • Preferred: CPHQ or ABQAURP, or Six Sigma certification Medical Terminology Certificate. • Required: None

🏖️ Benefits

• Health insurance • Flexible work arrangements • Professional development opportunities