As a Utilization Management Nurse at Aspire Health Plan, you will make sure our health services are administered efficiently and effectively. You will assess and interpret member needs and identify solutions that will help our members live healthier lives. The central goal of this position is to provide 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:

· Determine the appropriateness of inpatient and outpatient services following the evaluation of medical guidelines and benefit determinations.

· Identify and report any quality of care concerns that occur while members are in acute care and/or SNF facilities.

· Support AHP’s compliance to regulatory and accreditation requirements for both state and federal agencies.

· Support quality audits, chart audits, and reviews of medical records as needed for either complex high-cost cases or cases with quality of care concerns.

· Coordinate case management on complex cases that require additional clinical management support.

· Participate in Clinical Rounds with the Chief Medical Officer.

Responsibilities

· Conducts initial review of prior authorization or pre-certification requests for determination of coverage for members covered by sponsored health benefit plans.

· Makes determinations based on the medical necessity of plan-covered services based on internal policies reviewed and approved by the Medical Director of the plan. Where appropriate, involve the Medical Director if a partial or fully adverse medical necessity determination is expected based on the initial review.

· Works collaboratively with the Director of UM to achieve all daily/weekly and monthly targets.

· Participates in and supports all medical management initiatives including, but not limited to ER visits, re-admissions, OOA utilization, and identification of potentially high-cost cases.

· Collaborates with care managers on care transitions for patients with an emphasis on high-risk patients at risk for readmission, as needed

Competencies

· Accountability and Dependability: Assumes responsibility for accomplishing duties in an effective and timely manner.

· 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 learn 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.

Position Requirements

· Active unrestricted RN license required in the State of California

· Working knowledge of Milliman Care Guidelines (MCG)

· 3-5 years experience working in a managed care environment.

· Pre-authorization and Concurrent review experience

· Utilization Management experience

· Support business hours of 8 AM to 5 PM, Monday-Friday PST

· Strong computer skills

Salary: $134,784.00

Aspire Health is an equal opportunity employer.

*All Telecommuters will be required to adhere to Aspire Health Plan’s Telecommuter policy

Assigned Work Hours: