Utilization Management Review Nurse (Per Diem) - Aspire Job Listing at Montage Health in Monterey, CA (Job ID 11)

Description

Welcome to Montage Health's application process!

Job Description:

Purpose of Position The central goal of this position is to provide active operational support and clinical expertise in the areas of health care services, member benefits and clinical operations for all AHP members to improve member and provider satisfaction as well as quality of care and health outcomes. The Utilization Review Nurse will:

• Actively participate in organizational determinations of coverage upon receiving authorization requests and monitor care provided to AHP members in terms of concurrent review, coordination of care, benefits and health care services as they relate to transitions of care and coverage under client health benefit plans.
• Identify and report any quality of care concerns that occur while members are in acute care and/or SNF facilities.
• Review and monitor the monthly UM data reports to identify performance to BD targets, re admits or extended LOS and will develop and implement action plans for facilities as appropriate to help achieve targets.
• Coordinate with the Director of HCS in achieving continued process improvement of overall medical operations to increase efficiency, accuracy, automation and best practice reporting.
• Collaborate on the enhancements and updates to clinical programs, policies/procedures and process flows.
• Support AHPs compliance to regulatory and accreditation requirements for both state and federal agencies.
• Develop and implement enhanced clinical tools to achieve standardization in process and data collection, identify areas where efficiencies can be achieved with a focus on eliminating manual processes, minimize paper files as appropriate, evaluate current data reporting and discontinue reports that are not actionable.
• Actively support and participate in the CMS Quality Improvement Program (CCIP and QIP) in terms of achieving the goals and enhancing the future expansion. Will be an integral part of the team for ongoing monitoring and expansion.
• Participate in quality audits, chart audits, and reviews of medical records as needed for either complex high cost cases or cases with quality of care concerns.

• Support the development and implementation of BH and SA data reporting, monitoring, managing and tracking of these members for improved health outcomes, and addressing psychosocial challenges when needed.
• Coordinate with CHI CM on complex cases that require additional clinical management support.
• Collaborate with the Director of HCS in support of the AHP QIC and PAC Committees as needed.

Responsibilities

• Conducts initial review of prior authorization or pre certification requests for organizational determination of coverage for members covered by sponsored health benefit plans.
• Makes determinations based on medical necessity of plan-covered services based on internal policies reviewed and approved by the Medical Director of the plan. Where appropriate, involves the Medical Director if a partial or fully adverse medical necessity determination is expected based on the initial review.
• Monitors UM data reports monthly (ER, IP, RA, LOS, OOA and PHCC) and implements action plans as needed when utilization is above target, to improve performance. Works collaboratively with the Director of HCS to achieve all UM targets monthly.
• Perform telephonic reviews in local hospitals for specific cases when information is not forthcoming on hospitalized members (e.g. SVMH, Natividad or MEE). Decision for onsite will be on a case by case determination based on complexity of case.
• Review and approve all authorization/denial letters for accuracy and compliance to regulations (State and Federal).
• Assist the Director of HCS in the support of delegation oversight audits of contracted vendors as needed.
• Participate in and supports all medical management initiatives including, but not limited to: ER visits, re admissions, OOA utilization and identification of potential high cost cases.
• Consult with care managers on care transitions for patients with an emphasis on high risk patients at risk for readmission, as needed.
• Coordinate information flow with re-insurance and TPA for high cost cases for all LOBs.
• Monitor the monthly bed day reporting and identifying areas of high utilization in order to develop and implement a plan of action if needed.
• Work with the Medical Director and Director of HCS to develop and implement new and/or updated policies, procedures and processes to support the evolution of medical management programs.
• Work closely with delegated UM vendor to manage complex cases in acute care

facilities and provides support for concurrent review as needed.

• For complex cases at SVMH and/or Natividad, may be required to do on site reviews for UM or QI.
• Document and monitor projects and initiatives in collaboration with Director of HCS
• In collaboration with the Director of HCS will monitor discharge planning efforts and outcomes at all contracted facilities.

• Participate in all CMS site reviews and document findings.
• Participate in negotiations for special cases, or out of area care as needed.

Competencies

• Accountability and Dependability: Assumes responsibility for independently accomplishing duties in an effective and timely manner while exercising excellent
• Problem Solving and Decision Making: Identifies, analyzes, organizes, and solves problems and issues in a timely, effective manner; uses data and input from others to make sound, timely decisions even in the face of uncertainty.
• Integrity: Consistently honors commitments and takes responsibility for actions and words.
• Software and Computer Skills: Proficient in the use of Microsoft Office Suite, Highly skilled at using the Internet must be able to prepare documents, reports, spreadsheets and analyses on his/her own. Must learn and teach effectively with computer-based and/or online training.
• Flexibility: Demonstrates adaptability and openness to alternative solutions and flexibility when interacting with others, understanding their attitudes, needs, interests, and perspectives.
• Organizational Skills. This position requires someone with exceptional and demonstrable organizational skills.
• Inclusiveness: The ability to network and partner with all internal and external stakeholders including broad and diverse representation of private/public and traditional/non-traditional community organizations.

Position Requirements

• Active CA RN license. If not currently licensed in CA, must obtain temporary CA license immediately upon hire. Evidence of valid CA RN license required 6 months from hire date.
• Working knowledge of either InterQual or Milliman Guidelines and the ability to use one or both.
• A working knowledge of UM and CM industry targets, benchmarks and best practice.
• At least 5 years' experience working in a managed care environment
• Experience in a management position preferred
• Ability to interpret data reports and implement action plans based on the findings
• Some travel to contracted facilities (SVMH, Natividad and MEE).
• Travel for delegation oversight visits to vendors as needed.
• Strong computer and capabilities in MS Word and Excel
• Master's degree preferred
• Ability to participate in and support the goals, vision and overall direction of a system designed to care for a population of patients across the care continuum, linking particularly with medical home-based primary care sites and a distributed care network.

About Aspire Aspire Health Plan is a locally owned Medicare Advantage HMO that provides comprehensive medical coverage to seniors and other Medicare recipients in Monterey County. We're proud to be a community-centered organization backed by Community Hospital of the Monterey Peninsula and Salinas Valley Memorial Hospital. Over 700 doctors, many other healthcare providers, and all four Monterey County hospitals are part of the Aspire Health Plan network. It's the care you need from people you know.

Hourly Rate: $60

Aspire Health is an equal opportunity employer.

Assigned Work Hours:

Varied hours

Position Type:

Per Diem

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