Senior Manager, Inpatient Utilization Management (California LVN / RN Required)

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 Senior Manager, Inpatient Utilization Management (California LVN / RN Required) under the direction of the Director of UM, is responsible for ongoing management of the UM Department, oversees clinical staff, ensuring efficient, appropriate, and cost-effective inpatient care by reviewing medical records against guidelines for necessity, managing denials, coordinating discharge planning, and liaising with facilities, physicians, and families to maintain high quality and compliance. They lead teams, develop programs, analyze data, and implement process improvements, requiring strong leadership, clinical judgment, and knowledge of CMS guidelines.

This role is remote-eligible within the United States. Candidates may be based in any state; however, periodic travel to our headquarters in Orange, California is required (approximately 1–2 times per quarter) for leadership meetings, planning sessions, and team engagement. Business travel expenses will be covered in accordance with company policy.

This is an exempt, full-time position. While specific work hours may vary based on business needs, this role is expected to maintain regular availability during standard business hours to support an inpatient utilization management team that operates Monday–Friday, 8:00 AM–5:00 PM Pacific Time. Occasional flexibility outside of these hours may be required to support operational priorities.

Job Duties/Responsibilities:

• Leadership & Oversight: Manage, train, and mentor a team of UM/Case Managers; enforce performance standards; handle denials and appeals.
• Clinical Review: Conduct/oversee concurrent review of inpatient stays for medical necessity, appropriateness, and length of stay, using tools like Milliman (MCG) or Medicare manuals.
• Coordination: Act as a liaison between patients, families, providers, and facilities; ensure smooth care transitions and discharge planning.
• Compliance & Documentation: Ensure documentation meets regulatory and payer requirements; maintain accurate patient records.
• Resource Management: Identify opportunities to improve cost-effectiveness while maintaining quality of care.
• Reporting: Prepare reports on quality, utilization, and cost savings for leadership. 

SUPERVISORY RESPONSIBILITIES:

Oversee assigned staff. Responsibilities include recruiting, selecting, orienting, and training employees; assigning workload; planning, monitoring, and appraising job results; and coaching, counseling, and disciplining employees. 

JOB REQUIREMENTS:

Experience:

• Minimum 2-3 years recent and related supervisor experience required.
• Minimum 5 years related experience in a managed care setting, which includes inpatient and preservice utilization management required.
• Minimum 1-2 years recent experience with Medicare Advantage preferred.

Education:

• Successful completion of an accredited Registered Nursing Program or Vocational Nursing program required.
• Bachelor's Degree, Health/Clinical degree (BSN, PA), or business related (Business, Health Administration) preferred.

Specialized Skills:

• Knowledge of Medicare Managed Care Plans and CMS regulatory requirements required.
• Computer Skills: Word, Excel, Microsoft Outlook
• Experience with the application of clinical criteria (i.e., MCG, InterQual, CMS National and Local Coverage Determinations, etc.) required.

Licensure: 

• Must have and maintain an active, valid, and unrestricted LVN and/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.
• CCM or ABQAURP certification preferred.

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: $98,550.00 - $147,825.00

Pay range may be based on a number of factors including market location, education, responsibilities, experience, etc.

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 careers@ahcusa.com.