Utilization Review RN - Aspire Health Plan - Aspire Quality & Care Mgmt
Aspire Health Plan
Aspire Quality & Care Mgmt
Associate Degree Required
RN, Utilization Review
- Excellent pay and generous benefits, including continuing education allowance
- Excellent team-oriented culture
- Excellent work environment!
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.
- 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.
- Other duties as assigned
- Experience working in a managed care environment preferred
- Strong computer and capabilities in MS Word and Excel required
- Working knowledge of either InterQual or Milliman Guidelines and the ability to use one or both is preferred
- A working knowledge of UM and CM industry targets, benchmarks and best practice preferred
- Ability to interpret data reports and implement action plans based on the findings preffered
- 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 required
- As need to obtain licensure
- BSN and/or MSN preferred
- Active California RN license
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.
Aspire Health Plan is an equal opportunity employer.
Job Reference #: 108483