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Job: Utilization Review Nurse - Aspire Quality & Care Mgmt

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Jobing Description

Aspire Health Plan

Aspire Quality & Care Mgmt

Full Time (Exempt)

Day shift

Monday - Friday, days

80

ASP1707

Company Overview

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

  1. Community Hospital of the Monterey Peninsula (CHOMP) a 250 bed tertiary hospital,
  2. Community Health Innovations (CHI) an accountable care services organization, and
  3. Montage Medical Group, a 1204(a) multispecialty clinic.

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 Montage 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 Utilization Review Nurse will:

  1. 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.
  2. Identify and report any quality of care concerns that occur while members are in acute care and/or SNF facilities.
  3. 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.
  4. Coordinate with the Director of HCS in achieving continued process improvement of overall medical operations to increase efficiency, accuracy, automation and best practice reporting.
  5. Collaborate on the enhancements and updates to clinical programs, policies/procedures and process flows.
  6. Support AHPs compliance to regulatory and accreditation requirements for both state and federal agencies.
  7. 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.
  8. 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.
  9. 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.
  10. 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.
  11. Coordinate with CHI CM on complex cases that require additional clinical management support.
  12. Collaborate with the Director of HCS in support of the AHP QIC and PAC Committees as needed.

Position Requirements

  1. Active RN license
  2. Strong computer and capabilities in MS Word and Excel

Position Preferences

  1. Working knowledge of either InterQual or Milliman Guidelines and the ability to use one or both.
  2. A working knowledge of UM and CM industry targets, benchmarks and best practice.
  3. At least 5 years' experience working in a managed care environment.
  4. Bachelor's Degree
  5. Ability to interpret data reports and implement action plans based on the findings
  6. 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.

Equal Opportunity Employer

Skills / Requirements

Important Notes

 
 
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