Inpatient Review Nurse, California RN/LVN License Required

🔥 0 minutes ago

🏄 California – Remote

🏄 California – Remote

💵 $77.9k - $116.9k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

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Alignment Health

WebsiteLinkedInAll Job Openings

501 - 1000 employees

Founded 2013

⚕️ Healthcare Insurance

💰 $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

• Assure 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. • Performs reviews of inpatients with complex medical and social problems. • Generates referrals to contracted ancillary service providers and community agencies with the agreement of the patient’s primary care physician. • Performs follow-up reviews and evaluations of patients in the ambulatory care or lower level of care setting. • Effectively communicates with patients, their families and or support systems, and collaborates with physicians and ancillary service providers to coordinate care activities. • Identifies Members who may need complex or chronic case management post discharge and warm handoff to appropriate staff for ambulatory follow up, as necessary. • Communicates and collaborates with IPA/MG as necessary for effective management of Members. • Assigns and provides daily oversight of the activities and tasks of the CCIP Coordinator. • Records communications in EZ-Cap and/or case management database. • Arranges and participates in multi-disciplinary patient care conferences or rounds. • Monitors, documents, and reports pertinent clinical criteria as established per UM policy and procedure. • Monitors for any over utilization or underutilization activities. • Generates referrals as appropriate to the QM department. • Enters data as necessary for the generation of reports related to case management. • Reports the progress of all open cases to the Medical Director, Director of Healthcare Services and Manager of Utilization Management. • Performs other duties as assigned.

🎯 Requirements

• Minimum (3) years' general case management skills. • Minimum (2) years' experience utilizing Milliman Care Guidelines to justify Inpatient versus Observation Length of stay. • Minimum (2) consecutive years related experience in a managed care setting as an inpatient case manager. • Ability to communicate positively, professionally and effectively with others. • Excellent critical thinking skills related to nursing utilization review. • Knowledge of Medicare Managed Care Plans. • Effective written and oral communication skills. • Ability to establish and maintain a constructive relationship with diverse members, management, employees and vendors. • Ability to perform mathematical calculations and calculate simple statistics correctly. • Advanced problem-solving skills. • Preferred: Experience with a senior population.

🏖️ Benefits

• Health insurance • Flexible work arrangements • Professional development opportunities