Alignment Health·California
Review prior authorization requests for medical necessity using CMS and Milliman Care Guidelines for inpatient and outpatient services. Collaborate with providers and medical directors to ensure high-quality, cost-effective care for senior members.
Alignment Health is breaking the mold in conventional health care, committed to serving seniors and those who need it most: the chronically ill and frail.
It takes an entire team of passionate and caring people, united in our mission to put the senior first.
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 Health community.
Working at Alignment Health provides an opportunity to do work that really matters, not only changing lives but saving them.
Together.
Alignment Health is seeking a remote UM Nurse, Pre-Service (California RN/LVN 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.
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.
CPHQ or ABQAURP, or Six Sigma certification Medical Terminology Certificate.
Requires a valid California RN or LVN license and at least 3 years of clinical nursing experience, including 1 year in pre-service utilization management. Candidates must have experience with managed care (Medicare/Medicaid) and be willing to obtain licensure in other specified states.
Market context
California nursing roles often draw steady demand, especially for experienced RNs in procedural and critical care settings. Competition is strongest for candidates who already hold a California RN license, current BLS and ACLS, and recent ICU, ER, or PACU experience. Review the AI-summarized requirements and benefits on this platform to save research time, then confirm your certifications and highlight relevant bedside and procedural experience in your application.
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