About the Alliance Coal Health Plan
The Alliance Coal Health Plan is a single employer health plan established for the benefit of the employees and dependents of Alliance Resource Partners, L.P. (ARLP). The Health Plan is committed to supporting the health and well-being of our workforce through high-quality, cost-effective care.
Alliance Resource Partners, L.P. is a leading producer and marketer of coal and owner of mineral and royalty interests. ARLP is committed to providing reliable energy while maintaining a strong focus on employee safety and environmental responsibility.
Position Summary
The Utilization Review and Preauthorization Nurse plays a critical role in evaluating medical services for medical necessity, benefit eligibility, and compliance with plan guidelines before care is provided. As a key member of the Utilization Review team, this role ensures efficient authorization processing, supports high-quality care outcomes, and promotes compliance with regulatory standards. The Specialist serves as a central point of communication between healthcare providers, members, and internal departments.
Key Responsibilities
Authorization Processing & Utilization Review
- Review and process prior authorization requests for outpatient services, imaging, procedures, medications, and DME.
- Verify member eligibility and coverage based on plan guidelines.
- Apply clinical criteria (e.g., MCG) to determine medical necessity.
- Approve or escalate requests in accordance with clinical protocols.
- Collaborate with Medical Directors or Nurse Managers on complex or high-cost cases.
- Ensure accurate documentation of authorization decisions and rationale.
Communication & Customer Service
- Communicate decisions professionally and within required timeframes to providers and members.
- Provide compassionate, responsive support for provider and member inquiries.
- Educate providers and internal teams on plan requirements and documentation standards.
- Resolve authorization-related issues and escalate when necessary.
Compliance & Documentation
- Maintain compliance with HIPAA, URAC, NCQA, and internal plan policies.
- Monitor turnaround times to ensure regulatory adherence.
- Maintain detailed, accurate records of all authorization activity.
Collaboration & Operational Support
- Coordinate with Care Coordination, Case Management, Claims, and Customer Service teams.
- Contribute to quality improvement efforts and share utilization trends with leadership.
- Support policy and workflow enhancements through insights from day-to-day operations.
Qualifications
Education & Experience
- Associate or bachelor’s degree in a healthcare-related field with nursing preferred.
- RN or Licensed Practical Nurse (LPN) preferred. Other clinical certifications with relevant experience will be considered.
- At least 2 years of experience in utilization review, preauthorization, or a related healthcare setting.
- Familiarity with MCG, InterQual, or similar clinical guidelines preferred.
- Working knowledge of CPT, HCPCS, and ICD-10 coding is strongly preferred.
Skills & Competencies
- Excellent critical thinking and clinical interpretation skills.
- Strong written and verbal communication.
- Detail-oriented with the ability to manage multiple priorities.
- Proficiency in Microsoft Office (Word, Excel, Outlook) and electronic utilization systems required.
Working Conditions
- Full-time, in-office position.
- Standard business hours: 8:00 AM – 5:00 PM, Monday through Friday.
Benefits Overview
- No-cost health insurance for employees and their families (no premiums, deductibles, coinsurance, or copays for in-network services).
- Access to a 100% covered on-site clinic for employees and dependents.
- 401(k) plan with up to 8% employer contributions.
- Eligibility for an annual discretionary bonus.
- Comprehensive dental, vision, and life insurance.
- Health and dependent care flexible spending accounts.
Ready to join a team that prioritizes high-quality care, operational excellence, and the well-being of our members? Apply today and be part of a mission-driven health plan serving the employees and families of Alliance Resource Partners.