Review prior authorization requests for medical necessity using CMS and MCG guidelines to ensure high-quality, cost-effective care. Collaborate with providers and medical directors to process referrals and manage appeals and grievances.
Requirements summary
Requires a valid California RN or LVN license and at least 3 years of clinical nursing experience, including 1 year in pre-service utilization management. Must have experience with managed care (Medicare/Medicaid) and proficiency in ICD-10 and CPT coding.
high schoolassociate degreebachelor degreeCase ManagementTime ManagementProblem SolvingMedical TerminologyMicrosoft ExcelMicrosoft WordMicrosoft OutlookCPT CodingICD-10 CodingManaged CareMedical Necessity ReviewPrior AuthorizationUtilization ManagementCMS GuidelinesWritten and Verbal CommunicationMilliman Care Guidelines (MCG)
Job description
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 (LVN or RN, active California license required) to join our growing UM team.
In this role, you’ll review prior authorization requests for medical necessity across inpatient and outpatient services, applying CMS guidelines and Milliman Care Guidelines (MCG) to support timely, accurate determinations.
You’ll partner closely with providers and medical directors to ensure members receive high-quality, cost-effective care.
This is a fast-paced, production-driven role ideal for nurses with recent pre-service UM experience in a managed care setting who are comfortable managing multiple cases, meeting turnaround time expectations, and collaborating cross-functionally in a fully remote environment.
Schedule
Option A: - Monday –
Friday, 8:00 AM – 5:00 PM Pacific Time (must be able to consistently work these hours) - Candidates must reside within Pacific, Mountain, or Central time zones to align with business hours. -
Weekend rotation: approximately 1 weekend day every 5–6 weeks (4–8 hour shift between 8:00 AM – 5:00
PM
Pacific
Time)
Option B: -
Tuesday -
Saturday, 8:00 AM – 5:00 PM Pacific Time (must be able to consistently work these hours) - Candidates must reside within Pacific, Mountain, or Central time zones to align with business hours. - No weekend rotation required.
General
Duties /
Responsibilities: 1. Review pre-certification requests for medical necessity and refer to medical director any referral that requires additional expertise. 2. Utilize CMS guidelines (LCD, NCD) to assist in determinations of referrals and utilize Milliman Care Guidelines (MCG) to assist in determinations of referrals. 3. Maintain goals for established turn-around time (TAT) for referral processing. 4. Initiate single service agreements (SSA) when services required are not available in network. 5. Maintain a professional rapport with providers, physicians, support staff and patients in order to process pre-certification referrals as efficiently as possible. 6. Verify eligibility and / or benefit coverage for requested services. 7. Verify accuracy of ICD 10 and CPT coding in processing pre-certification requests. 8. Contact requesting provider and request medical records, orders, and / or necessary documentation in order to process related pre-service requests / authorizations when necessary. 9. Review referral denials for appropriate guidelines and language. 10. Assist medical directors in reviewing and responding to appeals and Grievances 11. Contact members and maintain documentation of call for expedited requests. 12. Other duties as assigned.
Job
Requirements:
Experience:
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
Milliman
Care
Guidelines (MCG)
Education:
Required: High School Diploma or GED.
Preferred:
Associates or
Bachelor's degree in
Nursing
Licensure:
Required: 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.
Training
Required: None
Preferred: Medical Terminology.
Six
Sigma
Specialized
Skills:
Required: 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 verbal communication skills; able to establish and maintain a constructive relationship with diverse members, management, employees and vendors.
Mathematical
Skills: Able to perform mathematical calculations and calculate simple statistics correctly.
Reasoning
Skills: Able 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 and
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. 1. 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. 2. 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: $77,905.00 - $116,858.00 Pay range may be based on a number of factors including market location, education, responsibilities, experience, etc. 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 careers@ahcusa.com. Alignment Health is championing a new path in senior care that empowers members to age well and live their most vibrant lives. Our mission-focused team makes high-quality, low-cost care a reality for members every day. Alignment Health is breaking the mold in conventional health care, committed to serving seniors and those who need it most. We believe that great work comes from people who are inspired to be their best. We've built a team of people who want to make a difference in the lives of the seniors we serve. Come join the team that is changing health care — one person at a time.
