Inpatient Review Nurse (RN/LVN) Must have California Licensure

About the position

The Inpatient Review Nurse (RN/LVN) at Alignment Health plays a crucial role in the utilization management team, focusing on assisting patients through their continuum of care. This fully remote position requires a California nursing license and involves collaboration with various healthcare professionals to ensure that patients receive appropriate and cost-effective care. The nurse will perform reviews of inpatient cases, coordinate care, and communicate effectively with patients and their families, all while adhering to established guidelines and policies.

Responsibilities
• Perform reviews of inpatients with complex medical and social problems.
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• Generate referrals to contracted ancillary service providers and community agencies with the agreement of the patient's primary care physician.
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• Perform follow-up reviews and evaluations of patients in the ambulatory care or lower level of care setting.
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• Review inpatient admissions timely and identify appropriate level of care and continued stay based on acceptable evidence-based guidelines.
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• Effectively communicate with patients, their families, and support systems, and collaborate with physicians and ancillary service providers to coordinate care activities.
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• Identify members who may need complex or chronic case management post-discharge and facilitate warm handoff to appropriate staff for ambulatory follow-up.
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• Communicate and collaborate with IPA/MG as necessary for effective management of members.
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• Assign and provide daily oversight of the activities and tasks of the CCIP Coordinator.
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• Record communications in EZ-Cap and/or case management database.
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• Arrange and participate in multi-disciplinary patient care conferences or rounds.
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• Monitor, document, and report pertinent clinical criteria as established per UM policy and procedure.
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• Monitor for any over-utilization or under-utilization activities.
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• Generate referrals as appropriate to the QM department.
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• Enter data as necessary for the generation of reports related to case management.
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• Report the progress of all open cases to the medical director, director of healthcare services, and manager of utilization management.

Requirements
• Successful completion of an accredited Licensed Vocational Nursing Program.
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• Current, active, and unrestricted California Licensed Vocational Nurse.
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• Experience with concurrent review required.
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• Experience utilizing Milliman Care Guidelines (MCG) required.
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• Minimum of (2) consecutive years related experience in a managed care setting as an inpatient case manager.
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• Minimum (3) years of general case management experience.
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• Knowledge of Medicare Managed Care Plans.
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• Possess excellent critical thinking skills related to nursing.
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• Strong written and verbal communication skills.
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• Strong interpersonal skills to establish and maintain constructive relationships with diverse members, management, employees, and vendors.
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• Able to perform mathematical calculations and calculate simple statistics correctly.
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• Able to prioritize multiple tasks; advanced problem-solving skills.
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• Able to use advanced reasoning to define problems, collect data, establish facts, draw valid conclusions, and design, implement and manage appropriate resolution.
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• Effective problem solving, organizational and time management skills and ability to work in a fast-paced environment.

Nice-to-haves
• Experience in complex/catastrophic case management preferred.
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• Proficient in Microsoft Word, Excel, and Outlook.

Benefits
• Competitive salary range of $74,600.00 - $100,000.00 annually.
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• Fully remote work environment.
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• Continuous learning and growth opportunities.
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• Supportive company culture that encourages sharing unique ideas and perspectives.

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