Utilization Management Nurse, LVN or RN (Temporary) -CA Licensure required)

Location: Orange, California US


Job Number: 4316

Position Title: Utilization Management Nurse

External Description:

The UM Nurse is responsible for reviewing requests for pre-certification for both inpatient and or outpatient services for all plan members. The UM Nurse works in collaboration with providers, Regional and Senior Medical Directors to assure timely processing of referrals to provide the highest quality medical outcomes that are most cost efficient. 

General Duties/Responsibilities: (May include but are not limited to)

• 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

• Utilize Miliman Guidelines to assist in determinations of referrals.

• Knowledge of CMS chapter 13

• Maintain goals for established turn-around time (TAT) for referral processing.

General UM 

• 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.

• Monitor Fax Folders, System Queues and Email for incoming requests.

• 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.

• 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

• Contact members and maintain documentation of call for Expedited requests.

• Assist with UM queue calls relating to UM review and pre-service status when needed.

• 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 Manager.

Supervisory Responsibilities:


Minimum Requirements:

1. Minimum Experience:

a. At least 1 year experience with Medicaid and/or Medicare required. 1-2 years’ experience in a medical setting working with IPAs, entering referrals/prior authorizations preferred. Knowledge of ICD-10, CPT codes, Managed Care Plans, medical terminology (certificate preferred) and referral system (Access Express/Portal/N-coder).

b. A minimum of three years of relevant professional experience.

c. Knowledgeable with CMS guidelines and regulations.

d. Experience with the application of clinical criteria (i.e., Milliman, Interqual, Apollo, CMS National and Local Coverage Determinations, etc.)

2. Education/Licensure:

a. RN preferred, LVN required with clinical experience.

b. Current, Active and Unrestricted California Nursing license; CPHQ or ABQAURP, or Six Sigma certification preferred.

c. Minimum Associate’s degree, Bachelor’s degree preferred.

3. Other:

a. Knowledge of Medicare Managed Care Plans

b. Computer Skills:  Word, Excel, Microsoft Outlook

c. Experience with the application of UM criteria (i.e., CMS National and Local Coverage Determinations, etc.)

d. Bilingual (English/Spanish) preferred

e. Positive, team player attitude

f. 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.

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.


City: Orange

State: California

Location City: Orange

Location State: California

Community / Marketing Title: Utilization Management Nurse, LVN or RN (Temporary) -CA Licensure required)

Company Profile:

Alignment Health was founded with a mission to revolutionize health care with a serving heart culture. Through its unique integrated care delivery models, deep physician partnerships and use of proprietary technologies, Alignment is committed to transforming health care one person at a time.

By becoming a part of the Alignment Health team, you will provide members with the quality of care they truly need and deserve. We believe that great work comes from people who are inspired to be their best. 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 community.

EEO Employer Verbiage:

Alignment requires all new hires to follow local and/or state requirements regarding the COVID-19 vaccine and booster.  If applicable, proof of vaccination and booster will be required as a condition of employment subject to legal exemptions.  This policy, which Alignment reserves the right to modify, is part of Alignment’s ongoing efforts to ensure the safety and well-being of its staff and community and to support public health efforts.

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 [email protected].

*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’s talent acquisition team, please email [email protected].