IP Concurrent Review Nurse

Job Number: 1417

Workplace Type:

Position Title: IP Concurrent Review Nurse

External Description:

Alignment Healthcare is seeking a concurrent review nurse to review requests for inpatient and skilled nursing facilities (SNF) services for all plan members. As the concurrent review nurse, you will be working in collaboration with providers and medical directors to ensure timely processing of referrals and to provide the highest quality and most cost-efficient medical outcomes.

Essential Duties and Responsibilities

May include but are not limited to:

• Utilize CMS guidelines (LCD, NCD) to assist in determinations of referrals
• Utilize Milliman Guidelines to assist in determinations of referrals.
• Work with medical director(s) when the request does not meet guidelines,
• Knowledge of CMS chapter 13, Condition Code 44, IPPS Final Rule (2 Midnight Rule)
• Meet required by CMS turn-around time (TAT) for referral processing (expedited and routine).
• Work with medical director issuing NOMNC, IDN using appropriate guidelines and language.
• Initiate single service agreements (SSA) when the required services are not available in network.
• Maintain a professional rapport with providers, physicians, support staff and patients to process pre-certification referrals as efficiently as possible.
• Monitor fax folders, system queues, and email for incoming requests.
• Verify eligibility and / or benefit coverage for requested services.
• Verify accuracy of ICD 10 and CPT coding in processing pre-certification requests.
• Contact requesting provider and request medical records, orders, and / or necessary documentation to process related pre-service requests/authorizations when necessary.
• Accurately documents referral process and any pertinent determination factors within the referral system.
• Participate in daily clinical rounds with medical director presenting new admissions, discussing appropriate Level of Care (LOS) and discussing daily census,
• Assist with mailing or faxing correspondence to PCP’s, specialists, related to requests / authorizations as needed.
• Contact members and maintain documentation of call for expedited requests.
• Recognize work-related problems and contributes to solutions.
• Meet specific deadlines (responds to various workloads by assigning task priorities according to department policies, standards and needs).
• Maintain confidentiality of information between and among health care professionals.
• Other duties as assigned by supervisor.

Minimum Requirements

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily.  The requirements listed below are representative of the knowledge, skill, and / or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• Experience:
  • Minimum 2 years’ experience in a medical setting working with individual physicians’ associations (IPA)
  • Experience with the application of UM criteria (i.e., CMS National and Local Coverage Determinations, etc.)
  • Case management experience required
  • Inpatient experience required
  • Experience entering referrals / prior authorizations.
  • Experience with referral system (Access Express/Portal/N-coder).
• Education:
  • High School Diploma or general education degree (GED) and / or training; or equivalent combination of education and experience.
• Certificates, Licenses, Registrations:
  • LVN and / or LPN required
  • Medical terminology certificate
• Other Qualifications:
  • Knowledge of ICD-10, CPT codes
  • Knowledge of Medicare Managed Care Plans
  • Proficient in Microsoft Office suite of products (Word, Excel, Microsoft Outlook, etc.)
  • Bilingual English / Spanish (preferred)
  • Possess positive and team player attitude
  • Excellent relationship management skills

Skills and Abilities

• Language Skills: Effective written and verbal communication skills; able to establish and maintain a constructive relationship with diverse members, management, employees and vendors;
• Mathematical Skills: Able to perform mathematical calculations and calculate simple statistics correctly
• Reasoning Skills: 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;
• 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.
• Transplant knowledge a plus

Work Environment

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job.  Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• Office setting within a medical care center.
• The noise level in the work environment is usually moderate.
• Duties performed primarily telephonically.

City: Orange

State: California

Location City: Orange

Location State: California

Community / Marketing Title: IP Concurrent Review Nurse

Company Profile:

By leveraging our world-class technology platform, innovative care delivery models, deep physician partnerships and our serving heart culture, Alignment Health is revolutionizing health care for seniors! From member experience professionals and clinicians, to data scientists and operations leaders, we have built a talented and passionate team that is deeply committed to our mission of transforming health care for the seniors we serve. Ready to join us?

At Alignment, delivering exceptional care to seniors starts with ensuring an exceptional experience for our over 1,300 employees. At the center of our employee experience is a culture where employees at all levels and across all teams are encouraged to share their unique ideas and perspectives. After all, when you can bring your authentic self to work, whether that’s in a clinical setting, our corporate office or a home office, creativity and innovation flourish! Another important part of the Alignment culture is a belief in continuous learning and growth. As a result, in this fast-growing company, you will find ample support to grow your skills and your career – with us.

EEO Employer Verbiage:

 

Please note: All clinical positions are contingent upon successful engagement with Alignment Health’s COVID-19 Vaccination program (fully vaccinated with documented proof or approved exception/deferral).

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.

*DISCLAIMER: Please beware of recruitment phishing scams affecting Alignment Health and other employers where individuals receive fraudulent employment-related offers in exchange for money or other sensitive personal information. Please be advised that Alignment Health and its subsidiaries will never ask you for a credit card, send you a check, or ask you for any type of payment as part of consideration for employment with our company. If you feel that you have been the victim of a scam such as this, please report the incident to the Federal Trade Commission at https://reportfraud.ftc.gov/#/. If you would like to verify the legitimacy of an email sent by or on behalf of Alignment Health’s talent acquisition team, please email [email protected].