Remote UM Nurse - Pre-Service (Must have North Carolina LVN / RN License)

Alignment Healthcare LLC; Nevada (IA); À distance; USD 77 000 - 117 000; Plein temps

Résumé du poste

An established industry player is seeking a dedicated Remote UM Nurse to join their Utilization Management team. This role involves reviewing pre-certification requests for medical necessity, collaborating with healthcare providers, and ensuring efficient processing of referrals. The ideal candidate will have a strong nursing background, experience in utilization management, and excellent communication skills. This position offers a unique opportunity to contribute to the well-being of seniors while working in a supportive and innovative environment. If you're passionate about making a difference in healthcare and thrive in a collaborative setting, this role is perfect for you.

Qualifications

• 3+ years nursing experience in clinical settings required.
• Experience in Utilization Management and managed care is essential.

Responsabilités

• Review pre-certification requests and ensure compliance with guidelines.
• Collaborate with medical directors for timely processing of referrals.

Connaissances

Nursing Experience

Utilization Management

ICD-10 Coding

CPT Coding

Problem-Solving Skills

Communication Skills

Mathematical Skills

Formation

High School Diploma or GED

Associates or Bachelor's degree in Nursing

Outils

Microsoft Word

Microsoft Excel

Microsoft Outlook

Description du poste

Remote UM Nurse - Pre-Service (Must have North Carolina LVN / RN License)

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.

Alignment Health is seeking a remote Utilization Management (UM) Nurse - Pre-service to join the UM team. As a UM Nurse, you will be responsible for reviewing requests for pre-certification for both inpatient and outpatient services for all plan members. You will 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 are looking for an opportunity to join an expanding company, learn and grow, be part of a collaborative team, and make a positive impact in the lives of seniors - we're looking for YOU!

Schedule:

• Monday - Friday, 8:00 AM - 5:00 PM Pacific Time.
• Weekend rotation: 1 weekend day every 5-6 weeks for 4 hour or 8 hour shift between 8:00AM - 5:00 PM Pacific Time.

GENERAL DUTIES / RESPONSIBILITIES:

1. Reviews pre-certification requests for medical necessity and refer to Medical Director any referral that requires additional expertise.
2. Utilizes CMS guidelines (LCD, NCD) to assist in determinations of referrals and utilizes Milliman Care Guidelines (MCG) to assist in determinations of referrals.
3. Maintains goals for established turn-around time (TAT) for referral processing.
4. Initiates single service agreements (SSA) when services required are not available in network.
5. Maintains a professional rapport with providers, physicians, support staff and patients in order to process pre-certification referrals as efficiently as possible.
6. Verifies eligibility and/or benefit coverage for requested services.
7. Verifies accuracy of ICD 10 and CPT coding in processing pre-certification requests.
8. Contacts requesting provider and request medical records, orders, and/or necessary documentation in order to process related pre-service requests/authorizations when necessary.
9. Reviews referral denials for appropriate guidelines and language.
10. Assist medical directors in reviewing and responding to appeals and Grievances.
11. Contacts members and maintain documentation of call for expedited requests.
12. Other duties as assigned.

Job Requirements:

Experience:

• 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 MCG (Milliman Care Guidelines).

Education:

• Required: High School Diploma or GED.
• Preferred: Associates or Bachelor's degree in Nursing.

Licensure:

• Required: Possess current, active and unrestricted LVN and/or RN license in North Carolina (Compact).
• Immediately upon hire, must obtain LVN and/or RN licensure in California (non-compact), Nevada (Non-compact), Arizona (Compact), and Texas (Compact) which will be reimbursed by company.

Preferred:

• CPHQ or ABQAURP, or Six Sigma certification.
• Medical Terminology Certificate.

Specialized Skills:

• 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 oral communication skills; ability to establish and maintain a constructive relationship with diverse members, management, employees and vendors.
• Mathematical Skills: Ability to perform mathematical calculations and calculate simple statistics correctly.
• Reasoning Skills: Ability 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.

Essential Physical 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

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.