Remote Inpatient Utilization Review Nurse

Alignment Healthcare USA, LLC; Orange (CA); Remote; USD 78,000 - 117,000; Full time

Job summary

Alignment Health is seeking an inpatient review nurse to join the remote utilization management team. The role focuses on reviewing inpatients with complex medical needs, coordinating with PCPs, facilities, and community resources to ensure appropriate, cost-effective care while maintaining safety and quality.

Qualified candidates hold an active LVN or RN license in California and have several years in managed care settings.

Qualifications

• Minimum 3 years of general case management skills.
• Minimum of two years using Milliman Care Guidelines for inpatient vs observation decisions.
• Two consecutive years in managed care as an inpatient case manager.
• Experience with a senior population preferred.
• Active LVN or RN license in California (Non-Compact).

Responsibilities

• Performs reviews of inpatients with complex medical and social problems.
• Generates referrals to contracted service providers and community agencies.
• Performs follow-up reviews in ambulatory or lower levels of care.
• Identifies appropriate level of care and continued stay based on guidelines.
• Communicates with patients and families, and coordinates care with physicians and providers.

Skills

Inpatient utilization review

Milliman Care Guidelines

Case management

Communication

Critical thinking

Education

LVN or RN license (California)

Associates or Bachelors degree (preferred)

Tools

EZ-Cap

Case management database/software

Job description

Alignment Health is seeking an inpatient review nurse to join the remote utilization management team. The role focuses on reviewing inpatients with complex medical needs, coordinating with PCPs, facilities, and community resources to ensure appropriate, cost-effective care while maintaining safety and quality.

Qualified candidates hold an active LVN or RN license in California and have several years in managed care settings.