Utilization Management Nurse, Lead

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. It takes an entire team of passionate and caring people, united in our mission to put the senior first. 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. Together.

The Utilization Management Nurse Lead is responsible for reviewing requests for inpatient and prior authorization services for all plan members. Works in collaboration with UM leaders and providers to ensure timely processing of referrals to provide the highest quality medical outcomes at the appropriate level of care. Oversees supports the team of UM Nurses with clinical decision-making tasks related to processing UM’s clinical referrals.

Job Duties/Responsibilities:
1.    Reviews reporting to assign tasks to UM Nurses for completion of time sensitive items.
2.    Works closely as a liaison between management and the team to ensure that new cases assigned are worked in a timely manner.
3.    Participates in department quality audits and vendor audits to assess timeliness of cases.
4.    Reports audit results and identifies opportunities for process improvement.
5.    Effectively communicates and keep 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.
6.    Assists with team coverage plans as needed.
7.    Collaborates with other leaders in the department to develop and improve processes and workflows.
8.    Acts as a resource to the team, members, providers, and community partners.
9.    Establishes and maintains effective interpersonal relationships with staff at all levels, providers, other departments, or programs.
10.    Leads, initiates and follows through on multiple projects simultaneously in a team environment.
11.    Lead Responsibilities:
_(a.    Mentors, trains, audits and coaches a team of UM Nurses to ensure compliance with Alignment policies and procedure and all regulatory requirements.
_(b.    Provides guidance to staff or directly manages complicated requests from members, providers, or staff. 
12.    Other duties as assigned.

Job Requirements

Experience:

• Required: Minimum of (3) consecutive years related experience in concurrent review and/or prior authorization at managed care organization. Minimum 2 years of experience using MCG

• Preferred: Prior leadership experience preferred

Education:

• Required: Successful completion of an accredited Licensed Vocational Nursing or Registered Nursing Program

Specialized Skills:

• Required:

• 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;
• Mathematical Skills:  Ability to perform mathematical calculations and calculate simple statistics correctly
• Reasoning Skills:  Ability to prioritize multiple tasks; advanced problem-solving; ability to use advanced reasoning to define problems, collect data, establish facts, draw valid conclusions, and design, implement and manage appropriate resolution.
• Problem-Solving Skills:  Effective problem solving, organizational and time management skills and ability to work in a fast-paced environment.
• Report Analysis Skills:  Comprehend and analyze statistical reports.

Licensure:

• Required: Current, active, and unrestricted California LVN or RN license

Essential Physical Functions:

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job.  Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

1.  While performing the duties of this job, the employee is regularly required to talk or hear. The employee regularly is required to stand, walk, sit, use hand to finger, handle or feel objects, tools, or controls; and reach with hands and