Nurse Care Management LPN (Virtual)

Alignment Health; Clayton (NC); Remote; USD 70,000 - 90,000; Full time

Job summary

Alignment Health is seeking an experienced inpatient review nurse to join our remote utilization management team. You will guide patients through the care continuum, collaborate with physicians and case managers, and ensure care is appropriate, cost-effective, and safe from admission through discharge.

The role emphasizes complex review, data entry, and multispecialty coordination, with a Pacific Time schedule. Candidates must hold LVN/RN licensure and pursue multi-state licensure as needed.

Qualifications

• 3+ years in general case management
• 2+ years using Milliman Care Guidelines for inpatient vs observation decisions
• 2 consecutive years in a managed care setting as an inpatient case manager
• Active LVN or RN license (California) with licensure in additional states to be pursued upon hire

Responsibilities

• Review inpatients with complex medical and social issues.
• Coordinate referrals to contracted providers and community services.
• Conduct follow-up reviews in ambulatory or lower levels of care.
• Assess hospital admissions for appropriate level of care and length of stay.
• Communicate with patients and families; collaborate with physicians and providers.

Skills

Utilization review

Case management

Milliman Care Guidelines

Critical thinking

Communication

Education

Licensed Vocational Nurse program

Associates or Bachelors Degree

Tools

EZ-Cap

Job description

Alignment Health is breaking the mold in conventional health care, committed to serving seniors and those who need it most: the chronically ill and frail. We have built a team of talented and experienced people who are passionate about transforming the lives of the seniors we serve. In this fast growing company, you will find ample room for growth and innovation alongside the Alignment Health community. Working at Alignment Health provides an opportunity to do work that really matters, not only changing lives but saving them.

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: Monday - Friday, 8:00 AM - 5:00 PM Pacific Time (Required)

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.
• 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.
• 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.

Required Qualifications / Experience

• Minimum 3 years of general case management skills.
• Minimum of two 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 related experience in a managed care setting as an inpatient case manager.
• Successful completion of an accredited Licensed Vocational Nursing Program.
• Associates or Bachelors Degree.
• Excellent critical thinking skills related to nursing utilization review.
• Knowledge of Medicare Managed Care Plans.
• Ability to use advanced reasoning to define problems, collect data, establish facts, draw valid conclusions, and design, implement and manage appropriate resolution.
• Report Analysis Skills: Knowledge and experience in complex catastrophic case management preferred.
• Must have and maintain an active, valid, and unrestricted LVN or RN license in California (Non-Compact).
• Immediately upon hire, must be willing to obtain LVN and or RN licensure in Nevada (Non-compact), Arizona (Compact), North Carolina (Compact), and Texas (Compact) which will be reimbursed by company.
• Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Alignment Health is an Equal Opportunity/Affirmative Action Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, age, protected veteran status, gender identity, or sexual orientation.