Utilization Management (UM) – Pre-Service (Remote | California RN / LVN | Pacific Time Schedule)
Not Disclosed•Full-TimeRemote
location_onRemote
About Alignment Health
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.
About the Role
We are seeking a remote Utilization Management (UM) Nurse – Pre-Service to join our growing UM team. In this role, you will 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 will 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 & Location
- Hours: Monday – Friday, 8:00 AM – 5:00 PM Pacific Time (must be able to consistently work these hours).
- Time Zones: 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).
Equal Opportunity & Safety
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.
Recruitment Safety Notice
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. 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, please report the incident to the Federal Trade Commission. To verify the legitimacy of an email sent by or on behalf of Alignment Health's talent acquisition team, please email careers@ahcusa.com.
Similar Job Opportunities
Skills, education and keywords
Skills: Utilization Management, CMS Guidelines, Milliman Care Guidelines, LCD, NCD, Single Service Agreements, Icd 10, CPT Coding, Access Express, N-Coder.
Education: High School Diploma or GED required; Associate's degree in Nursing preferred; Bachelor's degree in Nursing preferred.
Frequently asked questions about Utilization Management (UM) – Pre-Service (Remote | California RN / LVN | Pacific Time Schedule) at Alignment Health
What does a Utilization Management (UM) – Pre-Service (Remote | California RN / LVN | Pacific Time Schedule) at Alignment Health do?expand_more
Day-to-day, the Utilization Management (UM) – Pre-Service (Remote | California RN / LVN | Pacific Time Schedule) at Alignment Health will maintain established turnaround time goals for processing referral requests; initiate single service agreements when required services are not available in network; contact providers to request necessary medical records and documentation for authorization; and assist medical directors in reviewing and responding to appeals and grievances.
What are the requirements for this Utilization Management (UM) – Pre-Service (Remote | California RN / LVN | Pacific Time Schedule) role?expand_more
Alignment Health is looking for candidates who meet the following requirements: High School Diploma or GED; Active California LVN or RN license; 3+ years clinical nursing experience; 1+ year pre-service utilization management experience; 1+ year managed care (Medicaid/Medicare) experience; and 1+ year applying UM criteria (CMS).