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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