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

Alignment Health•Remote CA Outside Bay Area, CA

3d•$77,905 - $116,858•Remote

About The Position

Alignment Health is seeking an Inpatient Review Nurse to join its remote utilization management team. The nurse assists patients through the continuum of care in collaboration with the patient’s primary care physician, facility case manager, discharge planner, contracted ancillary service providers, and community resources as needed. The role ensures that services are provided at the most appropriate and cost-effective level of care to meet patients’ medical needs while maintaining safety and quality. The required schedule is Monday through Friday, 8:00 AM–5:00 PM Pacific Time. The role requires an active, valid, unrestricted California LVN or RN license. Upon hire, the employee must be willing to obtain additional nursing licenses in Nevada, Arizona, North Carolina, and Texas; the company reimburses these licenses.

Requirements

At least 3 years of general case management experience.
At least 2 years of experience using Milliman Care Guidelines to justify inpatient versus observation length of stay, including diagnosis and length-of-stay review.
Two consecutive years of related experience as an inpatient case manager in a managed care setting.
Successful completion of an accredited Licensed Vocational Nursing program.
Active, valid, unrestricted California LVN or RN license (non-Compact), which must be maintained.
Willingness to obtain LVN and/or RN licensure in Nevada (non-Compact), Arizona (Compact), North Carolina (Compact), and Texas (Compact) immediately upon hire; these licenses are reimbursed by the company.
Ability to communicate positively, professionally, and effectively; 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 and ability to establish and maintain constructive relationships with diverse members, management, employees, and vendors.
Ability to perform mathematical calculations and calculate simple statistics correctly.
Ability to prioritize multiple tasks; advanced problem-solving and reasoning skills; ability to define problems, collect data, establish facts, draw valid conclusions, and design, implement, and manage appropriate resolutions.
Effective problem-solving, organizational, and time-management skills, and ability to work in a fast-paced environment.
Ability to comprehend and analyze statistical reports.

Nice To Haves

Experience with a senior population.
Associate’s or bachelor’s degree.
Knowledge and experience in complex or catastrophic case management.

Responsibilities

Review inpatients with complex medical and social problems.
Generate referrals to contracted ancillary service providers and community agencies with the agreement of the patient’s primary care physician.
Perform follow-up reviews and evaluations of patients in ambulatory care or lower-level-of-care settings.
Review inpatient admissions promptly and identify appropriate level of care and continued stay using acceptable evidence-based guidelines used by AHC.
Communicate effectively with patients, their families or support systems, and collaborate with physicians and ancillary service providers to coordinate care.
Identify members who may need complex or chronic case management after discharge and provide a warm handoff to appropriate staff for ambulatory follow-up as necessary.
Communicate and collaborate with IPA/MG as necessary for effective member management.
Assign and provide daily oversight of the CCIP Coordinator’s activities and tasks.
Record communications in EZ-Cap and/or the case management database.
Arrange and participate in multidisciplinary patient care conferences or rounds.
Monitor, document, and report pertinent clinical criteria established by UM policy and procedure.
Monitor for overutilization or underutilization.
Generate referrals to the QM department as appropriate.
Enter data as necessary to generate case management reports.
Report the progress of all open cases to the Medical Director, Director of Healthcare Services, and Manager of Utilization Management.
Perform other duties as assigned.