Alignment Health
Healthcare
UtilizationManagement(UM)–Pre-Service
Neural analysis suggests this role is
optimal for Mid candidates.
“Utilization Management (UM) – Pre-Service at Alignment Health. Skills: Utilization Management, Prior authorization, CMS guidelines, RN/LVN. Review pre-certification requests for medical necessity. Refer to medical director for additional expertise”
What You'll Achieve.
Support timely, accurate determinations; Ensure members receive high-quality, cost-effective care; Meet turnaround time expectations
Industry & Context.
Prioritize multiple advanced problem-solving; Use advanced reasoning to define problems, collect data, establish facts, draw valid conclusions, and design, implement and manage appropriate resolution; Effective problem solving
Must reside within Pacific, Mountain, or Central time zones, Weekend rotation approximately 1 weekend day every 5–6 weeks, Regularly required to talk or hear, Regularly required to stand, walk, sit, use hand to finger, handle or feel objects, tools, or and reach with hands and arms, Frequently lifts and/or moves up to 10 pounds, Specific vision abilities required: close vision and ability to adjust focus
What They're Looking For.
Must Have
Active, valid, and unrestricted LVN or RN license in California, 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, Knowledge of ICD-10, CPT codes, managed care plans, medical terminology and referral system, Knowledgeable with CMS (Chapter 13) guidelines and regulations, Computer Skills: Word, Excel, Microsoft Outlook, Effective written and verbal communication, Able to perform mathematical calculations and calculate simple statistics correctly, Able to prioritize multiple 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, Effective problem solving, organizational and time management skills, Ability to work in a fast-paced environment, Comprehend and analyze statistical reports
Nice to Have
Associates or Bachelor's degree in Nursing, CPHQ or ABKQURP, or Six Sigma certification, Medical Terminology Certificate, Medical Terminology, Six Sigma, Bilingual English and Spanish, Transplant knowledge
What You'll Do.
Review pre-certification requests for medical necessity
Refer to medical director for additional expertise
Utilize CMS guidelines for determinations
Utilize Milliman Care Guidelines (MCG) for determinations
Maintain goals for established turn-around time (TAT)
Initiate single service agreements (SSA)
Maintain professional rapport with providers
Verify eligibility and / or benefit coverage
Verify accuracy of ICD 10 and CPT coding
Contact provider for medical records
Review referral denials for guidelines
Assist medical directors in reviewing appeals
Contact members for expedited requests
Maintain documentation of calls
How You'll Work.
Team & Collaboration
Partner closely with providers and medical directors; Collaborate cross-functionally; Maintain a professional rapport with providers, physicians, support staff and patients
Communication Scope
Effective written and verbal communication; Able to establish and maintain a constructive relationship with diverse members, management, employees and vendors
Full Job Description
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 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: Option A: \- 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) Option B: \- Tuesday - Saturday, 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. \- No week
Applying for this Utilization Management (UM) – Pre-Service role?
Most applicants get filtered before a human reads their resume. See if yours makes the cut.
How to Apply on Workday
- Workday has a multi-step form — save your progress after every section.
- "Apply With LinkedIn" can fail or lose data; manual entry is more reliable.
- Watch for the "Submit for Review" final step — hitting "Save" alone does not submit.
- Job requisition numbers are useful when following up with HR by email.
ANONYMOUS · UNFILTERED
What do employees actually say about Alignment Health?
Real rants from real employees. Read before you apply.