Remote Utilization Management Nurse - Pre-Service

Overview

Alignment Health is seeking a remote Utilization Management (UM) Nurse - Pre-service to join the UM team, responsible for reviewing requests for pre-certification for both inpatient and outpatient services for all plan members.

In Short

• Remote position requiring residence in North Carolina.
• Responsible for reviewing pre-certification requests for medical necessity.
• Collaborates with providers and medical directors for timely processing.
• Maintains established goals for referral processing turnaround time.
• Verifies eligibility and benefit coverage for requested services.
• Contacts providers for necessary documentation and medical records.
• Reviews referral denials for appropriate guidelines.
• Assists in reviewing and responding to appeals and grievances.
• Requires a minimum of 3 years nursing experience.
• Must possess an active LVN/RN license in North Carolina.

Requirements

• Minimum 3 years nursing experience in a clinical setting.
• At least 1 year experience in Utilization Management.
• Experience with managed care (Medicaid and/or Medicare).
• Familiarity with CMS National and Local Coverage Determinations.
• Knowledge of ICD-10 and CPT coding.
• Effective written and oral communication skills.
• Ability to prioritize multiple tasks and solve problems.
• Preferred: Associates or Bachelor's degree in Nursing.
• Preferred: CPHQ or ABQAURP certification.
• Preferred: Medical Terminology knowledge.

Benefits

• Opportunity for growth and innovation.
• Work-life balance with a remote position.
• Make a positive impact in the lives of seniors.
• Collaborative team environment.
• Comprehensive training and support.