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. , • 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 the ambulatory care or lower level of care setting. , • Review inpatient admissions timely and identify appropriate level of care and continued stay based on acceptable evidence-based guidelines. , • Effectively communicate with patients, their families, and 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 facilitate warm handoff to appropriate staff for ambulatory follow-up. , • 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 under-utilization 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. Requirements • 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. , • Strong written and verbal communication skills. , • Strong interpersonal skills to establish and maintain constructive relationships with diverse members, management, employees, and vendors. , • Able to perform mathematical calculations and calculate simple statistics correctly. , • Able to prioritize multiple tasks; advanced problem-solving skills. , • 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. Nice-to-haves • Experience in complex/catastrophic case management preferred. , • Proficient in Microsoft Word, Excel, and Outlook. Benefits • Competitive salary range of $74,600.00 - $100,000.00 annually. , • Fully remote work environment. , • Continuous learning and growth opportunities. , • Supportive company culture that encourages sharing unique ideas and perspectives. Apply Job!