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

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. Schedule: Monday - Friday, 8:00 AM - 5:00 PM Pacific Time 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. 5. 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. 6. Assists with team coverage plans as needed. Including jumping into operational support/work queues when 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: Onboarding & training of new hires, including live training sessions and presentations Mentors, trains, 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/supportive while still helping to maintain accountability 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 of 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:

• 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.

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 arms. 2. The employee frequently lifts and/or moves up to 10 pounds. Specific vision abilities required by this job include close vision and the ability to adjust focus. Pay Range: $85,696.00 - $128,543.00 Pay range may be based on a number of factors including market location, education, responsibilities, experience, etc.