Nurse Care Management LPN (Virtual)

Alignment Health; Phoenix (AZ); Remote; USD 85,000 - 110,000; Full time

Job summary

Alignment Health seeks an inpatient review nurse to join its remote utilization management team. You will assess inpatient stays, collaborate with PCPs, discharge planners, and providers to ensure appropriate and cost-effective care.

The role requires LVN or RN licensure (CA) with willingness to obtain licenses in NV/AZ/NC/TX, plus 3+ years of case management and Milliman Care Guidelines experience. Schedule is Mon–Fri, 8:00 AM–5:00 PM PT.

Qualifications

• Minimum 3 years of general case management skills.
• Two consecutive years using Milliman Care Guidelines to justify inpatient versus observation LOS.
• Two consecutive years related experience in a managed care setting as an inpatient case manager.
• Licensed LVN or RN with active CA license (Non-Compact).
• Willingness to obtain LVN/RN licenses in NV, AZ, NC, and TX per company reimbursement.
• Associates or Bachelors degree required.

Responsibilities

• Reviews inpatients with complex medical and social problems.
• Generates referrals to contracted providers with physician agreement.
• Performs follow-up reviews in ambulatory care or lower level of care settings.
• Reviews inpatient admissions for appropriate level of care and LOS per guidelines.
• Communicates with patients and families; coordinates with physicians and providers.
• Identifies patients needing chronic case management post-discharge and facilitates handoff.
• Records communications in EZ-Cap/case management system.
• Participates in multi-disciplinary patient care conferences or rounds.
• Monitors clinical criteria per UM policy and reports progress.
• Enters data for generation of case management reports.
• Reports progression of open cases to Medical Director and Manager.

Skills

Inpatient case management

Utilization review

Critical thinking

Communication with patients and their:

Milliman Care Guidelines knowledge

Data collection and reporting

Education

LVN or RN license (CA)

Active CA license, willingness to obtain NV/AZ/NC/TX licenses

Associate or Bachelor degree

Tools

EZ-Cap

Milliman Care Guidelines

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:

• 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.
• 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.