UM Nurse - Appeals & Claims Reviewer

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POST DATE 8/27/2016
END DATE 12/19/2016

Alignment Healthcare Orange, CA

Orange, CA
AJE Ref #
Job Classification
Full Time
Job Type
Company Ref #


osition Summary:

The UM Nurse Appeals and Claims Reviewer 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.


* Knowledge of Medicare Managed Care Manual Chapter 13
* Review appeals received in UM from A&G Dept.
* Review denied authorization along with all clinical notes and Medical Criteria
* Ensure that the proper medical criteria is utilized according to our company hierarchy of Medical Guidelines
* provide a detailed recommendation to UM MD
* Send complete file along with review/recommendation to UM MD for adjudication review
* Ensure that all appeals and grievance are processed timely to ensure compliance
* Maintain an A&G Log
* Communicate and work closely with A CPHQ or ABQAURP, or Six Sigma certification preferred.
* Minimum Associate's degree, Bachelor's degreepreferred.
* Other:
* Knowledge of Medicare Managed Care Plans
* Computer Skills: Word, Excel, Microsoft Outlook
* 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. 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.