Utilization Management Nurse – Pre-Service

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.

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