managed care nurse

WPS—A health solutions company

<div>
 Our
 
 Utilization Management RN (Registered Nurse)
 
 evaluates efficiency, appropriateness, and medical necessity for medical services, and procedures for our Health Plan. This role uses clinical knowledge to provide judgment to review medical services with evidence-based criteria, authorize requested services as appropriate. Our
 
 Utilization Management RN
 
 will be responsible for referring questionable cases to medical directors to prevent unnecessary procedures, treatments, or prolonged hospital stays.
 
 
 
 Salary Range
 
 
 
 
 $75,000 ~ $100,000
 
 
 
 
 The base pay offered for this position may vary within the posted range based on your job-related knowledge, skills, and experience.
 
 
 
 
 Work Location
 
 
 
 
 We are open to remote work in the following approved states:
 
 
 
 Colorado, Florida, Georgia, Illinois, Indiana, Iowa, Michigan, Minnesota, Missouri, Nebraska, New Jersey, North Carolina, Ohio, South Carolina, Texas, Virginia, Wisconsin
 
 
 
 How do I know this opportunity is right for me? If you:
 
 
 
 <ul>
 <li>
 Enjoy working with healthcare professionals to facilitate appropriate and quality services in a cost-effective manner to positively impact medical loss ratio.
 </li>
 <li>
 Can work closely with Medical Directors to facilitate decision-making process for the Health Services department.
 </li>
 <li>
 Have experience reviewing medical and behavioral health prior authorization requests for medical necessity and appropriateness of requested treatment according to medical policies and evidence-based criteria.
 </li>
 <li>
 Have experience working closely with members of Health Services, and key contacts in Sales, Member Services, Claims, Provider Contracting, and Billing &amp; Enrollment.
 </li>
 <li>
 Can document case summaries and refer cases to Medical Director that do not meet internal or external guidelines, policies, or medical criteria.
 </li>
 <li>
 Like to be accountable to monitor and maintain inventory in the Utilization Management queue to meet productivity standards.
 </li>
 <li>
 Enjoy evaluating, analyzing, and reporting trends in utilization changes in all healthcare delivery areas.
 </li>
 <li>
 Can make recommendations and implement changes consistent with Health Services objectives of quality care and reasonable cost.
 </li>
 <li>
 Would enjoy identifying opportunities and provide recommendations to improve department processes.
 </li>
 <li>
 Have Identified legal or liability issues and refer potential ethical or risk management issues to the appropriate department for resolution.
 </li>
 <li>
 Have participated in training new nursing staff on department workflows, policies, and procedures.
 </li>
 <li>
 Can work cross functionally to support other departmental efforts to ensure overall efficiency, quality, productivity, and compliance with all departmental, regulatory and URAC standards.
 
 
 </li>
 </ul>
 
 Minimum Qualifications
 
 
 
 <ul>
 <li>
 Registered Nurse (RN) with current licensure in the state of Wisconsin.
 </li>
 <li>
 4 or more years of experience as a Registered Nurse in varied clinical settings (i.e., hospital, clinic, home care, skilled nursing facility, etc.).
 </li>
 <li>
 2 or more years of experience in Managed Care (i.e., prior authorization, utilization review).
 </li>
 <li>
 Demonstrated experience managing and coordinating care effectively for case managed members.
 </li>
 <li>
 Strong knowledge of current medical practices, medical coding, trends and patterns of care.
 </li>
 <li>
 Familiarity with health plan operations, payer/provider relationships, and insurance benefits.
 </li>
 <li>
 Strong diverse experience and expertise that includes:
 </li>
 <ul>
 <li>
 The ability to work independently, manage a case load, and prioritization.
 </li>
 <li>
 Excellent analytical, critical thinking, problem-solving skills and decision-making skills.
 </li>
 <li>
 Excellent communication and interpersonal skills to work with members, providers, and teams
 </li>
 <li>
 Proficiency in Microsoft Office and healthcare software and systems.
 
 </li>
 </ul>
 </ul>
 
 Preferred Qualifications
 
 
 
 <ul>
 <li>
 Bachelor&rsquo;s degree in nursing (BSN).
 </li>
 <li>
 Health insurance background in Point of Service (POS), Preferred Provider Organization (PPO), or Medicare Supplement) plans.
 </li>
 <li>
 Knowledge of Utilization Review Accreditation Commission (URAC).
 </li>
 <li>
 Certified Managed Care Nurse (CMCN).
 </li>
 <li>
 Technical experience with word processing, spreadsheets, and proficiency with electronic medical record (EMR) systems and/or other managed care software.
 
 
 </li>
 </ul>
 
 Remote Work Requirements
 
 
 
 <ul>
 <li>
 High speed cable or fiber internet
 </li>
 <li>
 Minimum of 10 Mbps downstream and at least 1 Mbps upstream internet connection (can be checked at https://speedtest.net)
 </li>
 <li>
 Please review Remote Worker FAQs for additional information
 
 
 </li>
 </ul>
 
 Benefits
 
 
 
 <ul>
 <li>
 Remote and hybrid work options available
 </li>
 <li>
 Performance bonus and/or merit increase opportunities
 </li>
 <li>
 401(k) with a 100% match for the first 3% of your salary and a 50% match for the next 2% of your salary (100% vested immediately)
 </li>
 <li>
 Competitive paid time off
 </li>
 <li>
 Health insurance, dental insurance, and telehealth services start DAY 1
 </li>
 <li>
 Professional and Leadership Development Programs
 </li>
 <li>
 Review additional benefits: (https://www.wpshealthsolutions.com/careers/)
 
 
 </li>
 </ul>
 
 Who We Are
 
 
 
 WPS, a health solutions company, is a leading not-for-profit health insurer and federal government contractor headquartered in Madison, Wisconsin. WPS offers health insurance plans for individuals, families, seniors and group health plans for small to large businesses. We process claims and provide customer support for beneficiaries of the Medicare program and manage benefits for millions of active-duty and retired military personnel across the U.S. and abroad. WPS has been making healthcare easier for the people we serve for nearly 80 years. Proud to be military and veteran ready.
 
 
 
 Culture Drives Our Success
 
 
 
 WPS&rsquo; culture is where the great work and innovations of our people are seen, fueled and rewarded. We accomplish this by creating an open and empowering employee experience. We recognize the benefits of employee engagement as an investment in our workforce&mdash;both current and future&mdash;to effectively seek, leverage, and include differing and unique perspectives that fuel agility and innovation on high-performing teams. This results in people bringing their authentic selves to work every day in an organization that successfully adapts to business changes and new opportunities.
 
 
 We are proud of the recognition we have received from local and national organization regarding our culture and workplace: WPS Newsroom - Awards and Recognition.
 
 
 
 Sign up for
 
 
 Job Alerts
 
 
 
 
 FOLLOW US!
 
 
 
 
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 LinkedIn
 
 
 
 
 Facebook
 
 
 
 
 WPS Health Blog
 
</div>

Utilization Management RN

MJHS

<div><div><div>Req #:</div>
<div>4037</div> 
 
<div>Job ID:</div>
<div>15440</div> 
 
<div>Job Location:</div>
<div>New York, NY 
</div> 
<div>Zip Code:</div>
<div>10041</div> 
 
<div>Category:</div>
<div>Managed Care Nursing</div> 
 
<div>Agency:</div>
<div>Elderplan</div> 
 
<div>Status:</div>
<div>Regular Full-Time</div> 
 
<div>Office:</div>
<div>Remote After Training</div> 
 
<div>Salary:</div>
<div>$90,000.00 - $110,000.00 per year</div>
</div>The challenges of affordable healthcare continue to create new opportunities. Elderplan and HomeFirst, our Medicare and Medicaid managed care health plans, are outstanding examples of how we are expanding services in response to our patients' and members' needs. These high-quality healthcare plans are designed to help keep people independent and living life on their own terms. Even in a non-clinical role, employees have an opportunity to make a positive impact on the quality of our health plan members' lives.
The MJHS Difference
At MJHS, we are more than a workplace; we are a supportive community committed to excellence, respect, and providing high-quality, personalized health care services. We foster collaboration, celebrate achievements, and promote fairness for all. Our contributions are recognized with comprehensive compensation and benefits, career development, and the opportunity for a healthy work-life balance, advancement within our organization and the fulfillment of having a lasting impact on the communities we serve. 
Benefits include:<ul><li>
Sign-on Bonuses OR Student Loan Assistance for clinical staff</li><li>
FREE Online RN to BSN and MSN degree programs!</li><li>
Tuition Reimbursement for all full and part-time staff</li><li>
Dependent Tuition Reimbursement for clinical staff!</li><li>
Generous paid time off, including your birthday!</li><li>
Affordable and comprehensive medical, dental and vision coverage for employee and family members</li><li>
Two retirement plans! 403(b) AND Employer Paid Pension</li><li>
Flexible spending</li><li>
And MORE!</li></ul>
MJHS companies are qualified employers under the Federal Government&rsquo;s Paid Student Loan Forgiveness Program (PSLF)
Responsibilities:
Processes all requests for services in accordance with Medicare and NYS Medicaid Guidelines as well as departmental criteria and guidelines. Works collaboratively with other disciplines including Care Manager, Assessment Nurse and Primary Care Physician or other Specialists as necessary to ensure timely provision of services. Coordinates timely completion of UAS NY assessment that accurately reflects current condition of the member. Ensures that the member&rsquo;s Individualized Person-Centered Care Plan has been updated and accurately reflects present status of the member.
Qualifications:
<ul><li>Graduate of an accredited nursing program, Bachelor&rsquo;s preferred</li><li>
Knowledge with Utilization management processes preferred</li><li>
Current NY RN license and registration required</li><li>
CCM preferred</li><li>
Minimum three to five years nursing experience in long term care, managed care, home care, geriatrics or hospice</li><li>
Prior experience in an interdisciplinary service delivery environment preferred</li><li>
Working knowledge of Medicare and Medicaid regulations</li><li>
Prior experience in an interdisciplinary service delivery environment preferred</li><li>
Working knowledge of Windows, Word and Excel</li><li>
Knowledge of current standards of medical practice and healthcare delivery systems</li><li>
Strong assessment skills</li><li>
Knowledge of Interqual preferred</li></ul></div>

PreAuthorization RN

Elevance Health

<div>
 
 Nurse Appeals- Licensed Nurse
 
 
 
 
 Location:
 
 Virtual: This role enables associates to work virtually full-time, except for required in-person training sessions, providing maximum flexibility and autonomy. This approach promotes productivity, supports work-life integration, and ensures essential face-to-face onboarding and skill development.
 
 
 Please note that per our policy on hybrid/virtual work, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless an accommodation is granted as required by law.
 
 
 
 Hours
 
 : The work schedule for this position is Tuesday through Saturday with Sunday rotation. Business hours are 8 am to 8 pm EST, and the selected candidate must be able to work an 8-hour shift between those hours, including holidays on a rotational basis.
 
 
 The
 
 Nurse Appeals
 
 is responsible for investigating and processing and medical necessity appeals requests from members and providers.
 
 
 
 How You Will Make An Impact
 
 
 
 <ul>
 <li>
 Conducts investigations and reviews of member and provider medical necessity appeals.
 </li>
 <li>
 Reviews prospective, inpatient, or retrospective medical records of denied services for medical necessity.
 </li>
 <li>
 Extrapolates and summarizes medical information for medical director, consultants and other external review.
 </li>
 <li>
 Prepares recommendations to either uphold or deny appeal and forwards to Medical Director for approval.
 </li>
 <li>
 Ensures that appeals and grievances are resolved timely to meet regulatory timeframes.
 </li>
 <li>
 Documents and logs appeal/grievance information on relevant tracking systems and mainframe systems.
 </li>
 <li>
 Generates written correspondence to providers, members, and regulatory entities.
 </li>
 <li>
 Utilizes leadership skills and serves as a subject matter expert for appeals/grievances/quality of care issues and is a resource for clinical and non clinical team members in expediting the resolution of outstanding issues.
 
 
 </li>
 </ul>
 
 Minimum Requirements
 
 
 
 <ul>
 <li>
 Requires a HS diploma or equivalent and a minimum of 2 years of experience in a managed care healthcare setting; or any combination of education and experience, which would provide an equivalent background. Current active unrestricted RN license to practice as a health professional within the scope of licensure in applicable state(s) or territory of the United States required.
 
 
 </li>
 </ul>
 
 Preferred Skills, Capabilities And Experiences
 
 
 
 <ul>
 <li>
 AS or BS in Nursing preferred.
 </li>
 <li>
 Three to five years of clinical experience as a Registered Nurse strongly preferred.
 </li>
 <li>
 Have a current active unrestricted RN license to practice nursing within the scope of licensure in applicable state(s) or territory of the United States strongly preferred.
 </li>
 <li>
 Have two years in a managed care healthcare setting - reviewing medical records, investigation, and/or processing appeals within a managed care setting; or any combination of education and experience, which would provide an equivalent background strongly preferred.
 </li>
 <li>
 Experienced researching Medicare clinical guidelines: NCD, LCD; Medicare Benefit Policy and Milliman Care Guidelines is preferred.
 </li>
 <li>
 Experience reviewing claims and researching CPT codes or ICD-9 codes is preferred.
 </li>
 <li>
 Experience with Facets, Macess, and ACMP is preferred.
 
 
 </li>
 </ul>
 For candidates working in person or virtually in the below locations, the salary* range for this specific position is $72,492 to $108,738
 
 
 
 Locations: Latham, New York
 
 
 
 In addition to your salary, Elevance Health offers benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). The salary offered for this specific position is based on a number of legitimate, non-discriminatory factors set by the company. The company is fully committed to ensuring equal pay opportunities for equal work regardless of gender, race, or any other category protected by federal, state, and local pay equity laws.
 
 
 <ul>
 <li>
 The salary range is the range Elevance Health in good faith believes is the range of possible compensation for this role at the time of this posting. This range may be modified in the future and actual compensation may vary from posting based on geographic location, work experience, education, and/or skill level. Even within the range, the actual compensation will vary depending on the above factors as well as market/business considerations. No amount is considered to be wages or compensation until such amount is earned, vested, and determinable under the terms and conditions of the applicable policies and plans. The amount and availability of any bonus, commission, benefits, or any other form of compensation and benefits that are allocable to a particular employee remains in the Company's sole discretion unless and until paid and may be modified at the Company&rsquo;s sole discretion, consistent with the law.
 
 
 </li>
 </ul>
 Please be advised that Elevance Health only accepts resumes for compensation from agencies that have a signed agreement with Elevance Health. Any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of Elevance Health.
 
 
 Who We Are
 
 
 Elevance Health is a health company dedicated to improving lives and communities &ndash; and making healthcare simpler. We are a Fortune 25 company with a longstanding history in the healthcare industry, looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve.
 
 
 How We Work
 
 
 At Elevance Health, we are creating a culture that is designed to advance our strategy but will also lead to personal and professional growth for our associates. Our values and behaviors are the root of our culture. They are how we achieve our strategy, power our business outcomes and drive our shared success - for our consumers, our associates, our communities and our business.
 
 
 We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few.
 
 
 Elevance Health operates in a Hybrid Workforce Strategy. Unless specified as primarily virtual by the hiring manager, associates are required to work at an Elevance Health location at least once per week, and potentially several times per week. Specific requirements and expectations for time onsite will be discussed as part of the hiring process.
 
 
 The health of our associates and communities is a top priority for Elevance Health. We require all new candidates in certain patient/member-facing roles to become vaccinated against COVID-19 and Influenza. If you are not vaccinated, your offer will be rescinded unless you provide an acceptable explanation. Elevance Health will also follow all relevant federal, state and local laws.
 
 
 Elevance Health is an Equal Employment Opportunity employer and all qualified applicants will receive consideration for employment without regard to age, citizenship status, color, creed, disability, ethnicity, genetic information, gender (including gender identity and gender expression), marital status, national origin, race, religion, sex, sexual orientation, veteran status or any other status or condition protected by applicable federal, state, or local laws. Applicants who require accommodation to participate in the job application process may contact elevancehealthjobssupport@elevancehealth.com for assistance.
 
 
 Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state, and local laws, including, but not limited to, the Los Angeles County Fair Chance Ordinance and the California Fair Chance Act.
</div>

Nurse Appeals

TruHealth

<div>The RN Case Manager is primarily responsible for the daily management and support of the Case Management strategies for care coordination for a group of members who are associated with a Medicare Advantage plan. Visit (in person and/or telephonic) patients to ensure proper nursing care. Interview or correspond with physicians to correct errors or omissions and to investigate questionable claims. Consult and coordinate with health care team members to assess, plan, implement and evaluate patient care plans.
<div>
This position requires an individual who is a self-starter and team player, has the ability to manage multiple priorities, work with minimal supervision on assigned projects and activities, and demonstrates excellent communication and presentation skills. This individual must be able to adapt quickly to change and be able to collaborate with multiple teams

Here are a few of our benefits:
<ul>
<li>Annual performance wage increases</li>
<li>401k retirement plan with a company match</li>
<li>Medical, dental and vision insurance</li>
<li>$50,000 basic life insurance &ndash; paid by the company</li>
<li>Paid time off</li>
<li>UKG Wallet &ndash; access your pay faster!</li>
<li>Holiday pay</li>
<li>Telehealth through 98point6 &ndash; free to all employees</li>
<li>Continuing Education opportunities</li>
<li>Career Advancement Opportunities</li>
</ul>
Qualifications/Requirements:
<ul>
<li>Minimum of 2 years of experience in clinical nursing or rehabilitation for the geriatric population.</li>
<li>2-years managed care experience required.</li>
<li>Minimum of 3-5 years&rsquo; experience doing case management in a managed care environment preferably with a managed care organization or like facility, Preferred.</li>
</ul>
Essential Functions:
<ul>
<li>Complete Health Risk Assessments for members as assigned.</li>
<li>Initiate, update and/or revise care plans as needed.</li>
<li>Maintain a case load of patient as assigned.</li>
<li>Evaluates, coordinates, and plans patient care in collaboration with an interdisciplinary health team; reassesses and revises plans of care in collaboration with other members of the health care team.</li>
<li>Provides patient/family education based on identified learning needs utilizing available teaching resources</li>
<li>Provides education based on identified learning needs utilizing available teaching resources to members of the Home/Facility staff as needed.</li>
<li>Coordinates outpatient discharge planning based on patient needs, clinical circumstances and benefit coverage.</li>
<li>Participates in all Managed Care related audits; generates, maintains and tracks periodic and annual reports/documents via MS Office program, e-mails to support Care Coordination program.</li>
<li>Performs improvement projects involving development of monitoring/collection tools, review of medical records, data entry, analysis, and preparation of audit findings and reports.</li>
<li>Participates in patient care conferences, committee meetings, staff development and educational programs to increase or maintain professional competency.</li>
<li>Correctly applies medical management criteria.</li>
<li>Researches clinical questions from employers, members and payers as required.</li>
<li>Educate members on health access options.</li>
<li>Responds, manages, and resolves day-to-day problems presented in care coordination and communicates effectively with the Facility/Home.</li>
<li>Other duties as assigned.</li>
</ul>
Education:
<ul>
<li>Graduate of an accredited RN program.</li>
<li>Bachelor&rsquo;s Degree preferred.</li>
</ul>
Licensure/Certifications:
<ul>
<li>Current license to practice as a register nurse in assigned state.</li>
<li>Current CCM license, Preferred</li>
<li>CPR for Healthcare Professionals certification.</li>
<li>Current valid driver&rsquo;s license.</li>
<li>Current motor vehicle insurance.</li></ul></div></div>

RN Case Manager

Molina Healthcare

<div>
 JOB DESCRIPTION Job SummaryProvides support for clinical member services review assessment processes. Responsible for verifying that services are medically necessary and align with established clinical guidelines, insurance policies, and regulations - ensuring members reach desired outcomes through integrated delivery of care across the continuum. Contributes to overarching strategy to provide quality and cost-effective member care.
 
 
 
 Essential Job Duties
 
 
 
 <ul>
 <li>
 Assesses services for members to ensure optimum outcomes, cost-effectiveness and compliance with all state/federal regulations and guidelines.
 </li>
 <li>
 Analyzes clinical service requests from members or providers against evidence based clinical guidelines.
 </li>
 <li>
 Identifies appropriate benefits, eligibility and expected length of stay for requested treatments and/or procedures.
 </li>
 <li>
 Conducts reviews to determine prior authorization/financial responsibility for Molina and its members.
 </li>
 <li>
 Processes requests within required timelines.
 </li>
 <li>
 Refers appropriate cases to medical directors (MDs) and presents them in a consistent and efficient manner.
 </li>
 <li>
 Requests additional information from members or providers as needed.
 </li>
 <li>
 Makes appropriate referrals to other clinical programs.
 </li>
 <li>
 Collaborates with multidisciplinary teams to promote the Molina care model.
 </li>
 <li>
 Adheres to utilization management (UM) policies and procedures.
 
 
 </li>
 </ul>
 
 Required Qualifications
 
 
 
 <ul>
 <li>
 At least 2 years experience, including experience in hospital acute care, inpatient review, prior authorization, managed care, or equivalent combination of relevant education and experience.
 </li>
 <li>
 Registered Nurse (RN). License must be active and unrestricted in state of practice.
 </li>
 <li>
 Ability to prioritize and manage multiple deadlines.
 </li>
 <li>
 Excellent organizational, problem-solving and critical-thinking skills.
 </li>
 <li>
 Strong written and verbal communication skills.
 </li>
 <li>
 Microsoft Office suite/applicable software program(s) proficiency.
 
 
 </li>
 </ul>
 
 Preferred Qualifications
 
 
 
 <ul>
 <li>
 Certified Professional in Healthcare Management (CPHM).
 </li>
 <li>
 Recent hospital experience in an intensive care unit (ICU) or emergency room.
 
 
 </li>
 </ul>
 To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board.
 
 
 Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V
 
 
 Pay Range: $27.73 - $54.06 / HOURLY
 
 
 <ul>
 <li>
 Actual compensation may vary from posting based on geographic location, work experience, education and/or skill level.
 </li>
 </ul>
</div>

Care Review Clinician (RN)

Alignment Healthcare

<div>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 &ndash; Pre-Service (LVN or RN, active California license required) to join our growing UM team. 
 
In this role, you&rsquo;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&rsquo;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:
 
<ul><li>Monday &ndash; Friday, 8:00 AM &ndash; 5:00 PM Pacific Time (must be able to consistently work these hours)</li><li>Candidates must reside within Pacific, Mountain, or Central time zones to align with business hours.</li><li>Weekend rotation: approximately 1 weekend day every 5&ndash;6 weeks (4&ndash;8 hour shift between 8:00 AM &ndash; 5:00 PM Pacific Time)</li></ul>
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:<ul><li>
Minimum (3) years' nursing experience in clinical setting.</li><li>
Minimum (1) year experience UM experience with pre-service.</li><li>
Minimum (1) year experience with managed care (Medicaid and / or Medicare).</li><li>
Minimum 1 year of experience with the application of UM criteria (i.e., CMS National and Local Coverage Determinations, etc.)</li><li>
Minimum (1) year experience in a medical setting working with IPAs, entering referrals / prior authorizations preferred</li><li>
Minimum (1) Experience with the application of clinical criteria, specifically Milliman Care Guidelines (MCG)</li></ul>
Education:<ul><li>Required: High School Diploma or GED.</li><li>Preferred: Associates or Bachelor's degree in Nursing</li></ul>
Licensure:
Required:<ul><li>
Must have and maintain an active, valid, and unrestricted LVN or RN license in California (Non-Compact)</li><li>
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.</li></ul>
Preferred:<ul><li>
CPHQ or ABQAURP, or Six Sigma certification</li><li>
Medical Terminology Certificate.</li></ul>
Training:<ul><li>Required: None</li><li>Preferred: Medical Terminology. Six Sigma</li></ul>
Specialized Skills:
Required:<ul><li>
Knowledge of ICD-10, CPT codes, managed care plans, medical terminology and referral system (Access Express / Portal / N-coder).</li><li>
Knowledgeable with CMS (Chapter 13) guidelines and regulations.</li><li>
Computer Skills: Word, Excel, Microsoft Outlook</li><li>
Language Skills: Effective written and verbal communication skills; able to establish and maintain a constructive relationship with diverse members, management, employees and vendors.</li><li>
Mathematical Skills: Able to perform mathematical calculations and calculate simple statistics correctly.</li><li>
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.</li><li>
Problem-Solving Skills: Effective problem solving, organizational and time management skills and ability to work in a fast-paced environment.</li><li>
Report Analysis Skills: Comprehend and analyze statistical reports.</li></ul>
Preferred:<ul><li>
Bilingual English and Spanish</li><li>
Transplant knowledge a plus</li></ul>
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.<ul><li>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&rsquo;s talent acquisition team, please email careers@ahcusa.com.</li></ul></div>

Utilization Management (UM) – Pre-Service (Remote | California RN / LVN | Pacific Time Schedule)

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Utilization Management RN

PreAuthorization RN

Nurse Appeals

RN Case Manager

RN Case Manager

Care Review Clinician (RN)

Utilization Management (UM) – Pre-Service (Remote | California RN / LVN | Pacific Time Schedule)