Overview of the Role:
Alignment Health is seeking a remote inpatient review nurse (must have California license) to join the utilization management (UM) team. As an inpatient review nurse, you get to assist patients through the continuum of care in collaboration with the patient’s primary care physician, facility case manager, discharge planner and employing contracted ancillary service providers and community resources as needed. You will coordinate care with delegated and de-delegated groups to ensure 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.
Responsibilities:
- Perform reviews of 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 with collaboration of IPA / MG as necessary.
- Perform follow-up reviews and evaluations of patients in the ambulatory care or lower level of care setting.
- Review inpatient admissions timely and identifies appropriate level of care and continued stay based on acceptable evidence-based guidelines used by CCHP.
- Effectively communicate with patients, their families and or support systems, and collaborate with physicians and ancillary service providers to coordinate care activities.
- Identify members who may need complex or chronic case management post discharge and warm handoff to appropriate staff for ambulatory follow up as necessary.
- Communicate and collaborate with IPA / MG as necessary for effective management of Members.
- Assign and provide daily oversight of the activities and tasks of the CCIP Coordinator.
- Record communications in EZ-Cap and / or case management database.
- Arrange and participate in multi-disciplinary patient care conferences or rounds.
- Monitor, document, and report pertinent clinical criteria as established per UM policy and procedure.
- Monitor for any over utilization or underutilization activities.
- Generate referrals as appropriate to the QM department.
- Enter data as necessary for the generation of reports related to case management.
- Report the progress of all open cases to the medical director, director of healthcare services, and manager of utilization management.
Required Skills & Experience:
- Successful completion of an accredited Licensed Vocational Nursing Program
- Current, active, and unrestricted California Licensed Vocational Nurse.
- Experience with concurrent review required.
- Experience utilizing Milliman Care Guidelines (MCG) required.
- Minimum of (2) consecutive years related experience in a managed care setting as an inpatient case manager
- Minimum (3) years of general case management experience
- Knowledge of Medicare Managed Care Plans
- Possess excellent critical thinking skills related to nursing
- Experience in complex / catastrophic case management preferred
- Must be proficient in Microsoft Word, Excel, and Outlook
- Strong written and verbal communication skills
- Strong interpersonal skills to establish and maintain a constructive relationship with diverse members, management, employees and vendors.
- Able to perform mathematical calculations and calculate simple statics correctly
- Able to prioritize multiple tasks; advanced problem-solving
- Able 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
- Able to comprehend and analyze basic reports
- While performing the duties of this job, the employee is regularly required to sit; use hands to finger, hand, or feel and talk or hear.
- The employee is frequently required to reach with hands and arms
- The employee is occasionally required to climb or balance and stoop, or kneel
- The employee must occasionally lift and / or move up to 20 pounds.
- Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, depth perception and the ability to adjust focus.
United States
