Inpatient Review Nurse, California RN/LVN License Required

🕒 October 15

🇺🇸 United States – Remote

💵 $77.9k - $116.9k / year

⏰ Full Time

🟢 Junior

🟡 Mid-level

👻 Ghost score 0%

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Alignment Health

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501 - 1000 employees

Founded 2013

⚕️ Healthcare Insurance

🛡️ Insurance

🏥 Healthcare

💰 $135M Series C on 2020-03

Healthcare Insurance • Insurance • Healthcare

Alignment Health is dedicated to providing comprehensive care for Medicare members, emphasizing the needs of seniors, the chronically ill, and those who are frail. With a mission to transform senior healthcare, Alignment Health leverages a tailored care model and advanced technology to deliver high-quality, low-cost healthcare services. Their 24/7 concierge care team collaborates with trusted local providers to ensure that every member receives personalized care, reflecting the company's commitment to treating all members as valued family members.

📋 Description

• 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 in ambulatory care or lower-level-of-care settings • Review inpatient admissions timely and identify appropriate level of care and continued stay using evidence-based guidelines • Communicate with patients, families, and support systems and collaborate with physicians and ancillary service providers to coordinate care • Identify members needing complex or chronic case management after discharge and provide warm handoffs • Collaborate with IPA/MG for effective member management • Assign and provide daily oversight of the CCIP Coordinator’s activities and tasks • Record communications in EZ-Cap and/or the case management database • Arrange and participate in multidisciplinary patient care conferences or rounds • Monitor, document, and report pertinent clinical criteria according to UM policy and procedure • Monitor for overutilization or underutilization • Generate referrals to the Quality Management department as appropriate • Enter data for case management reports • Report progress of open cases to the Medical Director, Director of Healthcare Services, and Manager of Utilization Management • Perform other duties as assigned

🎯 Requirements

• Minimum 3 years of general case management skills • Minimum 2 years of experience utilizing Milliman Care Guidelines to justify inpatient versus observation length of stay, including review of diagnosis and length of stay • Two consecutive years of related experience in a managed care setting as an inpatient case manager • Successful completion of an accredited Licensed Vocational Nursing Program • Active, valid, and unrestricted LVN or RN license in California (Non-Compact) • Must be willing to obtain LVN and/or RN licensure in Nevada, Arizona, North Carolina, and Texas immediately upon hire • Ability to communicate positively, professionally, and effectively; provide leadership, teach, and collaborate • Excellent critical thinking skills related to nursing utilization review • Knowledge of Medicare Managed Care Plans • Effective written and oral communication skills and ability to maintain constructive relationships with diverse members, management, employees, and vendors • Ability to perform mathematical calculations and calculate simple statistics • Ability to prioritize multiple tasks and apply advanced problem-solving and reasoning • Effective problem-solving, organizational, and time management skills • Ability to work in a fast-paced environment • Ability to comprehend and analyze statistical reports

🏖️ Benefits

• Licensure reimbursement for LVN and/or RN licensure in Nevada, Arizona, North Carolina, and Texas

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