Inpatient Review RN / LVN Nurse (Must have California Licensure)
Alignment Healthcare
- California
- $73,600-100,000 per year
- Permanent
- Full-time
- Perform reviews of inpatients with complex medical and social problems.
- Generate referrals to contracted ancillary service providers and community agencies with the agreement of the patient's primary care physician.
- Perform follow-up reviews and evaluations of patients in the ambulatory care or lower level of care setting.
- Review inpatient admissions timely and identifies appropriate level of care and continued stay based on acceptable evidence based guidelines used by CCHP.
- Effectively communicate with patients, their families and or support systems, and collaborates with physicians and ancillary service providers to coordinate care activities.
- Identify 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.
- Monitor, document, and report pertinent clinical criteria as established per UM policy and procedure.
- Monitor for any over utilization or under utilization activities.
- Generate referrals as appropriate to the QM department.
- Enters data as necessary for the generation of reports related to case management.
- Report the progress of all open cases to the medical director, director of healthcare services, and manager of utilization management.
- Successful completion of an accredited Licensed Vocational Nursing Program
- Current, active, and unrestricted California Licensed Vocational Nurse.
- Experience with concurrent review required.
- Experience utilizing Milliman Care Guidelines (MCG) required.
- Minimum of (2) consecutive years related experience in a managed care setting as an inpatient case manager
- Minimum (3) years of general case management experience
- Knowledge of Medicare Managed Care Plans
- Possess excellent critical thinking skills related to nursing
- Experience in complex / catastrophic case management preferred
- Must be proficient in Microsoft Word, Excel, and Outlook
- Strong written and verbal communication skills
- Strong interpersonal skills to establish and maintain a constructive relationship with diverse members, management, employees and vendors.
- Able to perform mathematical calculations and calculate simple statics correctly
- Able to prioritize multiple tasks; advanced problem-solving
- Able to use advanced reasoning to define problems, collect data, establish facts, draw valid conclusions, and design, implement and manage appropriate resolution.
- Effective problem solving, organizational and time management skills and ability to work in a fast-paced environment
- Able to comprehend and analyze basic reports
- While performing the duties of this job, the employee is regularly required to sit; use hands to finger, hand, or feel and talk or hear.
- The employee is frequently required to reach with hands and arms
- The employee is occasionally required to climb or balance and stoop, or kneel
- The employee must occasionally lift and / or move up to 20 pounds.
- Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, depth perception and the ability to adjust focus.
Suite 1600
Orange, CA 92868Tel. 1-844-310-2247© 2024 Alignment Healthcare USA, LLC. All rights reserved.This website makes use of licensed stock photography. All photography is for illustrative purposes only. Some people depicted are models.