Sr. Utilization Management Nurse
Location: Orange, California US
Job Number: 1885
Position Title: Sr. Utilization Management Nurse
The Sr. Utilization Management Nurse is responsible for reviewing requests for pre-certification for both inpatient and or outpatient services for all plan members and for reviewing retrospective services to ensure proper claims payment is rendered. The Sr. Utilization Management Nurse works in collaboration with providers, Regional and Sr. Medical Directors to assure timely processing of referrals to provide the highest quality outcomes that are most cost efficient.
(May include but are not limited to)
- Review claims services to ensure proper DRG payments are rendered, ER facility claims to verify proper coding and process determinations on retrospective claims submissions & appeals
- Review member reimbursement requests to ensure medical necessity is met based on evidence of coverage
- Review pre and post-certification requests and follow referral workflow process to ensure auditing requirements are met
- Utilize CMS guidelines (LCD, NCD) to assist in determinations of referrals
- Utilize MCG Guidelines to assist in determinations of referrals
- Knowledge of CMS chapter 13
- Maintain goals for established turn-around time (TAT) for referral processing.
- Maintain a professional rapport with providers, physicians, support staff and patients in order to process pre-certification referrals as efficiently as possible
- Monitor Fax Folders, System Queues and Email for incoming requests
- Verify eligibility and/or benefit coverage for requested services
- Verify accuracy of ICD 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
- Accurately documents referral process and any pertinent determination factors within the referral system
- Review referral denials for appropriate guidelines and language
- Assist Medical Directors in reviewing and responding to Appeals and Grievances
- Support the development of workflows and job aids related to Pre-Service, Inpatient and Retro review processes
- Support the development and revision of Policies & Procedures related to UM functions and the training required to educate pertinent staff
- Recognize work-related problems and contributes to solutions
- Meet specific deadlines (responds to various workloads by assigning task priorities according to department policies, standards and needs)
- Maintain confidentiality of information between and among health care professionals.
- Other duties as assigned by UM leadership.
- Minimum Experience:
- At least 2 years’ experience with Medicaid and/or Medicare. 1-2 years’ experience in a medical setting working with IPAs, entering referrals/prior authorizations. Must of have knowledge of ICD-10, CPT codes, Managed Care Plans, medical terminology (certificate preferred) and referral system (Access Express/Portal/N-coder).
- A minimum of five years of relevant professional experience.
- Knowledgeable with CMS guidelines and regulations.
- Experience with the application of clinical criteria (i.e., MCG, Interqual, Apollo, CMS National and Local Coverage Determinations, Health Plan, etc.)
- RN with clinical experience.
- Current, Active and Unrestricted California Registered Nursing license
- CPHQ or ABQAURP, or Six Sigma certification preferred.
- Minimum Associate’s degree, Bachelor’s degree preferred.
- Knowledge of Medicare Managed Care Plans
- Computer Skills: Word, Excel, Microsoft Outlook, EZCap, EZMember, and Access Express
- Experience with the application of UM criteria (i.e., CMS National and Local Coverage Determinations, etc.)
- Bilingual (English/Spanish) preferred
- Positive, team player attitude
- Excellent relationship management skills
Skills and Abilities:
- 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.
- 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.
- 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.
Location City: Orange
Location State: California
Community / Marketing Title: Sr. Utilization Management Nurse
Who is Alignment Healthcare?
- Socially responsible
- Technologically enabled
- Concierge care
- Servant leadership
We are dedicated to transforming the complex and confusing process of medical treatment in the United States so that every link in the health care continuum becomes more efficient, productive, and effective. We built a team of people who want to make a difference. Come join the team that is changing health care one person at a time.
We believe that great work comes from people who are inspired to be their best. We invite you to explore our wide variety of roles based on your unique experience.
EEO Employer Verbiage:
Alignment Healthcare, LLC is proud to practice Equal Employment Opportunity and Affirmative Action. We are looking for diversity in qualified candidates for employment: Minority/Female/Disable/Protected Veteran.
If you require any reasonable accommodation under the Americans with Disabilities Act (ADA) in completing the online application, interviewing, completing any pre-employment testing or otherwise participating in the employee selection process, please contact firstname.lastname@example.org.