Utilization Management Nurse, Lead (Inpatient | Remote | Must have California LVN / RN License)

Alignment Health•Remote CA Outside Bay Area, CA

3d•$85,696 - $128,543•Remote

About The Position

The Utilization Management Nurse Lead is responsible for reviewing requests for inpatient and prior authorization services for all plan members. Works in collaboration with UM leaders and providers to ensure timely processing of referrals to provide the highest quality medical outcomes at the appropriate level of care. Oversees and supports the team of UM Nurses with clinical decision-making tasks related to processing UM’s clinical referrals. This is a remote position with a schedule of Monday - Friday, 8:00 AM - 5:00 PM Pacific Time.

Requirements

Minimum of (3) consecutive years of related experience in concurrent review and/or prior authorization at managed care organization.
Minimum (2) years of experience using MCG.
Knowledge of Medicare Managed Care Manuals and CMS regulatory requirements.
Ability to communicate positively, professionally and effectively with others; provide leadership, teach and collaborate with others.
Effective written and oral communication skills; ability to establish and maintain a constructive relationship 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; 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 and ability to work in a fast-paced environment.
Comprehend and analyze statistical reports.
Must have and maintain an active, valid, and unrestricted LVN or RN license in California (Non-Compact).
Immediately 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.

Nice To Haves

Prior leadership experience preferred.

Responsibilities

Reviews reporting to assign tasks to UM Nurses for completion of time sensitive items.
Works closely as a liaison between management and the team to ensure that new cases assigned are worked in a timely manner.
Participates in department quality audits and vendor audits to assess timeliness of cases.
Effectively communicates and keeps the Utilization Management leadership team informed of all departmental operations, activities, data, program performance, issues or any other pertinent information that would impact the overall program compliance or achievement of internal goals.
Assists with team coverage plans as needed, including jumping into operational support/work queues when needed.
Collaborates with other leaders in the department to develop and improve processes and workflows.
Acts as a resource to the team, members, providers, and community partners.
Establishes and maintains effective interpersonal relationships with staff at all levels, providers, other departments, or programs.
Leads, initiates and follows through on multiple projects simultaneously in a team environment.
Onboarding & training of new hires, including live training sessions and presentations.
Mentors, trains, audits and coaches a team of UM Nurses to ensure compliance with Alignment policies and procedures and all regulatory requirements.
Serves as first-line SME/resource for inpatient UM questions.
Provides 1:1 coaching/shadowing support when needed.
Provides guidance to staff or directly manages complicated requests from members, providers, or staff.
Other duties as assigned.