[Hiring] Inpatient Review Nurse @Alignment Health

Role Description

Alignment Health is seeking an inpatient review nurse to join the remote utilization management team. As an inpatient review nurse, you will 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. 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.

Schedule (Required):

• Monday - Friday
• 8:00 AM - 5:00 PM Pacific Time

General Duties / Responsibilities:

• 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.
• Reviews inpatient admissions timely and identifies appropriate level of care and continued stay based on acceptable evidence-based guidelines used by AHC.
• 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.

Qualifications

• Minimum (3) years' general case management skills.
• Minimum (2) years' experience utilizing Milliman Care Guidelines to justify Inpatient versus Observation Length of stay, including review of diagnosis and length of stay.
• Minimum (2) consecutive years related experience in a managed care setting as an inpatient case manager.
• Preferred: Experience with a senior population.
• Required: Successful completion of an accredited Licensed Vocational Nursing Program.
• Preferred: Associates or Bachelors Degree.

Requirements

• Ability to communicate positively, professionally, and effectively with others; provide leadership, teach, and collaborate 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.
• Mathematical Skills: Ability to perform mathematical calculations and calculate simple statistics correctly.
• Reasoning Skills: Ability to prioritize multiple tasks; advanced problem-solving; ability to use advanced reasoning to define problems, collect data, establish facts, draw valid conclusions, and design, implement, and manage appropriate resolution.
• Problem-Solving Skills: Effective problem solving, organizational and time management skills and ability to work in a fast-paced environment.
• Report Analysis Skills: Comprehend and analyze statistical reports.
• Preferred: Knowledge and experience in complex/catastrophic case management.

Benefits

• Pay Range: $77,905.00 - $116,858.00.
• Pay range may be based on a number of factors including market location, education, responsibilities, experience, etc.