[Hiring] Utilization Management Nurse – Pre-Service @Alignment Health

Role Description Alignment Health is seeking a remote Utilization Management (UM) Nurse – Pre-Service (LVN or RN, active California license required) to join our growing UM team. In this role, you’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’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:

• Monday – Friday, 8:00 AM – 5:00 PM Pacific Time (must be able to consistently work these hours)
• Candidates must reside within Pacific, Mountain, or Central time zones to align with business hours.
• Weekend rotation: approximately 1 weekend day every 5–6 weeks (4–8 hour shift between 8:00 AM – 5:00 PM Pacific Time)

General Duties / Responsibilities:

• Review pre-certification requests for medical necessity and refer to medical director any referral that requires additional expertise.
• Utilize CMS guidelines (LCD, NCD) to assist in determinations of referrals and utilize Milliman Care Guidelines (MCG) to assist in determinations of referrals.
• Maintain goals for established turn-around time (TAT) for referral processing.
• Initiate single service agreements (SSA) when services required are not available in network.
• Maintain a professional rapport with providers, physicians, support staff and patients in order to process pre-certification referrals as efficiently as possible.
• Verify eligibility and / or benefit coverage for requested services.
• Verify accuracy of ICD 10 and CPT coding in processing pre-certification requests.
• Contact requesting provider and request medical records, orders, and / or necessary documentation in order to process related pre-service requests / authorizations when necessary.
• Review referral denials for appropriate guidelines and language.
• Assist medical directors in reviewing and responding to appeals and Grievances.
• Contact members and maintain documentation of call for expedited requests.
• Other duties as assigned.

Qualifications

• 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).

Requirements

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

Benefits

• 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.

Essential Physical Functions

• 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.
• 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.

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