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.

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. Reports audit results and identifies opportunities for process improvement. 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. Assists with team coverage plans as 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. Lead Responsibilities: Mentors, trains, audits and coaches a team of UM Nurses to ensure compliance with Alignment policies and procedure and all regulatory requirements. Provides guidance to staff or directly manages complicated requests from members, providers, or staff. Other duties as assigned.