Manager of Utilization Review, RN - Aspire Quality & Care Mgmt
Aspire Health Plan
Aspire Quality & Care Mgmt
Full Time (Exempt)
Associate Degree Required
RN, Manager Utilization Review
· Excellent pay and generous benefits, including continuing education allowance
· Excellent team-oriented culture
· Excellent work environment!
The Manager of Utilization Review will provide active operational support and clinical expertise in the areas of health care services, member benefits and clinical operations for all Aspire Health Plan (AHP) members to improve member and provider satisfaction as well as quality of care and health outcomes.
· 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
· Other duties as assigned.
· 5 years' experience working in a managed care environment
· 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
· Ability to interpret data reports and implement action plans based on the findings
· Strong computer and capabilities in MS Word and Excel
· 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.
· As need to obtain licensure
· BSN and/or MSN preferred
· Active California RN license
Aspire Health Plan 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.
Aspire Health Plan is an equal opportunity employer.
Job Reference #: 108310