Utilization Management Nurse, Lead (Inpatient | Remote | Must have California LVN / RN License)

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. Our team is passionate and experienced, dedicated to transforming the lives of the seniors we serve while providing ample opportunities for growth and innovation. Utilization Management Nurse Lead Responsibilities Reviews reporting to assign tasks to UM Nurses for completion of time sensitive items. Works closely as a liaison between management and the team to ensure that new cases assigned are worked in a timely manner. Participates in department quality audits and vendor audits to assess timeliness of cases. Effectively communicates and keeps the Utilization Management leadership team informed of all departmental operations, activities, data, program performance, issues or any other pertinent information that would impact the overall program compliance or achievement of internal goals. Assists with team coverage plans as needed, including jumping into operational support/work queues when needed. Collaborates with other leaders in the department to develop and improve processes and workflows. Acts as a resource to the team, members, providers, and community partners. Establishes and maintains effective interpersonal relationships with staff at all levels, providers, other departments, or programs. Leads, initiates and follows through on multiple projects simultaneously in a team environment. Onboarding & training of new hires, including live training sessions and presentations; mentors, audits and coaches a team of UM Nurses to ensure compliance with Alignment policies and procedures and all regulatory requirements. Serves as first-line SME/resource for inpatient UM questions; provides 1:1 coaching/shadowing support when needed; available and approachable while still helping to maintain accountability. Provides guidance to staff or directly manages complicated requests from members, providers, or staff. Other duties as assigned. Requirements Minimum of (3) consecutive years of related experience in concurrent review and/or prior authorization at a managed care organization. Minimum (2) years of experience using MCG. Prior leadership experience preferred. Education Successful completion of an accredited Licensed Vocational Nursing or Registered Nursing Program. Specialized Skills Knowledge of Medicare Managed Care Manuals and CMS regulatory requirements. Ability to communicate positively, professionally and effectively with others; provide leadership, teach and collaborate with others. Effective written and oral communication skills; ability to establish and maintain a constructive relationship with diverse members, management, employees and vendors. Ability to perform mathematical calculations and calculate simple statistics correctly. Advanced problem‑solving and reasoning skills 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. Ability to comprehend and analyze statistical reports. Licensure 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 the company. Essential Physical Functions Regularly required to talk or hear; stand, walk, sit; use hand to finger, handle or feel objects, tools, or controls; and reach with hands and arms. Frequently lifts and/or moves up to 10 pounds. Specific vision abilities required include close vision and the ability to adjust focus. Pay Range $85,696.00 – $128,543.00. Pay may be based on a number of factors including market location, education, responsibilities, experience, etc. EEO Statement 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. #J-18808-Ljbffr E2E Alignment Healthcare USA, LLC