Job: Manager of Utilization Review - Aspire Quality & Care Mgmt

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Job Description

Aspire Health Plan

Aspire Quality & Care Mgmt

Full Time (Exempt)

Day shift




5 years experience required

Company Overview

The Aspire Health Plan (AHP) is a subsidiary of Montage Health. Other subsidiaries of Montage Health include:

· Community Hospital of the Monterey Peninsula (CHOMP) a 250 bed tertiary hospital,

· Community Health Innovations (CHI) a accountable care services organization, and

· Montage Medical Group, a 1204(a) multispecialty clinic.

· Coastal Third Party Administrators (CTPA) a wholly-owned subsidiary of Aspire Health Plan

Aspire introduced a new Medicare Advantage product line in 2014 to serve the needs of the Medicare eligible population in Monterey County. This population segment of our community represents one of the fastest growing segments of the county in coming years, and their demands for comprehensive health care and maintaining overall wellness are growing with their increasing numbers. By offering attractive Medicare Advantage plans, Aspire rounds out the services MH subsidiaries already provide, creating value added services for seniors to achieve the triple aim of improving care for the individual, reducing cost, and improving the health of the community.

In addition to the at-risk Medicare Advantage line of business, Aspire Health Plan also administers health plans for self-funded employer health benefit plans in the commercial sector. These services include comprehensive medical management and health plan analytic activities typical of well managed health plans. Aspire's proven practices provide added value for plan sponsors who recognize the importance of a holistic approach to plan management and the control of their employee health benefit expenses while ensuring access to the quality healthcare provided by their plans.

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 Manager of Utilization Review 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.

· Have a working knowledge of UM data reports that identify performance to BD targets, re-admits or extended LOS to provide back up as needed to CMO.

· Coordinate with the CMO 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.

· Support the implementation of 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 CMO in support of the AHP QIC and PAC Committees as needed.


· 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 CMO 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.

· Supports the monitoring of UM data reports monthly (ER, IP, RA, LOS, OOA and PHCC) and subsequent action plans as needed when utilization is above target, to improve performance. Works collaboratively with the CMO to achieve all UM targets monthly.

· Performs 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 and potential of case to reach Stop loss.

· Review and approve all authorization/denial letters for accuracy and compliance to regulations (State and Federal).

· Assists the CMO in the support of delegation oversight audits of contracted vendors as needed.

· Participates 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.

· Supports the CMO as needed in consulting with CHI care managers on care transitions for complex high cost patients as needed.

· Assists with the coordination of information flow with re-insurance and TPA for high cost cases in all lines of business.

· Supports the efforts at monitoring the monthly bed day reporting and identifying areas of high utilization in order to develop and implement a plan of action if needed.

· Works with the CMO to develop and implement new and/or updated policies, procedures and processes to support the evolution of medical management programs.

· Works 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 CMO

Position Requirements

· Active California RN license

· 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 or supervisory 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.

· Support business hours of 8:00 a.m. to 5:00 p.m., Monday-Friday

· 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.

Benefits Competitive benefit package

Salary Commensurate with experience

Aspire Health Plan is an equal opportunity employer.


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