Inpatient Review Nurse (Remote | California RN/LVN License Required | Pacific Time Schedule)

About the role

Alignment Health is seeking an inpatient review nurse to join the remote utilization management team. This position plays a crucial role in ensuring that patients receive the most appropriate level of care at the right time, aligning with the organization's mission to serve seniors and those who need it most.

Responsibilities

• Performs reviews of inpatients with complex medical and social problems.
• Generates referrals to contracted ancillary service providers and community agencies with the agreement of the patient’s primary care physician.
• Follows up with patients in the ambulatory care or lower level of care setting for reviews and evaluations.
• Affirms that services are provided at the most appropriate, cost-effective level of care needed to meet the patient’s medical needs while maintaining safety and quality.
• Communicates and collaborates with physicians and ancillary service providers to coordinate care activities.
• Identifies patients who may need complex or chronic case management post-discharge and coordinates with appropriate staff for follow-up care.
• Collaborates with IPA/MG as necessary for effective management of Members.
• Assigns and oversees the activities of the CCIP Coordinator.
• Records communications in EZ-Cap and/or case management database.
• Participates in multi-disciplinary patient care conferences or rounds.
• Maintains and documents pertinent clinical criteria as established per UM policy and procedure.
• Maintains awareness of any over-utilization or under-utilization activities.
• Generates referrals as appropriate to the QM department.
• Enters data as necessary for the generation of reports related to case management.
• Reports the progress of all open cases to the Medical Director, Director of Healthcare Services and Manager of Utilization Management.

Requirements

• Minimum (3) years' general case management skills.
• Minimum (2) years' experience utilizing Milliman Care Guidelines to justify Inpatient versus Observation.
• Length of stay: including review of diagnosis and length of stay.
• Minimum (2) consecutive years related experience in a managed care setting as an inpatient case manager.
• Experience with a senior population.

Qualifications

• Successful completion of an accredited Licensed Vocational Nursing Program.
• Associates or Bachelors Degree preferred.
• Ability to communicate positively, professionally and effectively with others; provide leadership, teach and collaborate with others.
• Excellent critical thinking skills related to nursing utilization review.
• Knowledge of Medicare Managed Care Plans.
• 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.

Specialized Skills

• Ability to communicate positively, professionally and effectively with others; provide leadership, teach and collaborate with others.
• Excellent critical thinking skills related to nursing utilization review.
• Knowledge of Medicare Managed Care Plans.
• 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.

Pay

The pay range for this position is $77,905.00 - $116,858.00. Pay range may be based on a number of factors including market location, education, responsibilities, experience, etc.

Schedule

Monday - Friday 8:00 AM - 5:00 PM Pacific Time

Benefits

Immediate 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.

Work Environment

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

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.