Remote Utilization Management (UM) Nurse (Must have California Licensure) at Alignment Healthcare USA, LLC in Orange, California

Job Description:

Overview of the Role:

Alignment Health is seeking a remote LVN / LPN utilization management (UM) Nurse (must have California license). 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.

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.

• Unrestricted LVN / LPN California licensure required.
• Minimum 2 years' experience 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, InterQual, Apollo, CMS National and Local Coverage Determinations, etc.) highly preferred.
• Strong knowledge of Medicare and Medicaid coverage benefits, CMS guidelines and regulations
• Computer proficient in Microsoft Outlook, Word and Excel
• Bilingual English / Spanish preferred.