At Alameda Alliance for Health (Alliance) we are striving each day to create a healthier community and to improve the quality of life of our members throughout our diverse County. As a part of our mission, we collaborate with our provider partners to address social determinants of health and to deliver high quality, accessible, and affordable health care services.
140 ULTILIZATION MANAGEMENT - Inpatient Util Mgmt Reviewer
The Inpatient Utilization Management (UM) RN is responsible for evaluating the clinical presentation of members in inpatient settings, utilizing the applicable clinical practice standards/guidelines to determine medical necessity for the level of care required by the member. The Inpatient UM RN (InPt UM RN) processes clinical and psychosocial information to ensure that members receive the appropriate care during the hospitalization and planning for post hospital care transitions. The position provides expert guidance to hospital staff and physicians on appropriate resources available to members to achieve the optimal functioning and stability in the post acute setting. The Inpt UM RNconducts on-site and telephonic evaluation of hospitalized members and initiates the transition of care process. The Inpatient UM RN works directly with hospitals and primary and specialty care providers to meet the targeted needs of each individual member and their families.
Principal responsibilities include:
EDUCATION OR TRAINING EQUIVALENT TO:
- Review of prospective, inpatient, or retrospective medical records of services for medical necessity, including records with data gathered by LVNs;
- Consultation with the Alliance Medical Director to validate patient acuity and plan of care;
- Extrapolate and summarizes medical information for Medical Director, consultants or other external review entities;
- Apply clinical medical necessity guidelines, policy and procedures, and EOC benefit guidelines;
- Obtain data from LVNs on patient factors to apply medical necessity guidelines and facilitate the plan of care.
- Prepare recommendations to either approve or deny, and forward recommendations for denial of payment to Medical Director for review;
- Document and logs clinical information, guidelines, referrals and actions taken in relevant tracking systems
- Perform bedside assessment and counseling of members, including discussions of goals and expectations upon discharge or transfer.
- Use clinical judgment to assess and stratify members for appropriate levels of need and refer member to the Case and Disease Management department, and the Health Homes Program as necessary.
- Identify patients eligible for hospital discharge or transfer to lower level of care; assist in coordinating discharge planning needs with hospital staff, vendors, etc.
- Coordinate with admitting, attending, PCP, LVNs, case manager, social workers, and other liaisons regarding the patient’s acuity level and plan of care.
- Participate in daily/weekly internal Alliance grand rounds. Participate in hospital grand rounds when appropriate.
- Evaluate and process, prior authorization requests for facility admissions, home health (PT/OT/ST/MSW), Durable Medical Equipment (DME), and out of area services.
- Perform timely concurrent reviews for patients belonging to delegate medical groups that seek inpatient admission out of the contiguous county.
- Identify members with medical conditions that may meet California Children’s Services (CCS) eligibility and coordinate with the plan CCS specialist for referral.
- Reconcile daily hospital census reports and face sheets against authorizations.
- Serve as the primary resource for inquiries and follow-up tasks related to the prior authorizations for the assigned hospital.
- Coordinate out of area patient transfers.
- Identify potential quality of care concerns and refer to the into the Potential Quality Issue (PQI) process or Medical Director for review.
- Initiate the disenrollment process of Medi-Cal members and work in collaboration with UM coordinators to make sure the appropriate disenrollment process is implemented.
- Work closely with the Alliance Management or clinical personnel to clarify the reasons for modification, deferral, or denial of an authorization request.
- Support the Inpatient UM staff with administrative and clinical tasks as needed, including back-up coverage at hospitals as needed.
- Provide weekend coverage, when required, for assigned hospitals to ensure member discharge needs are met.
- Provide on call coverage during the weekend for contracted hospitals; frequency to be determined by manager, based on staff availability
- Assist the Manager, Inpatient Utilization Management in tracking utilization and operational trends at hospitals and implementing solutions.
- Work with various departments at the Alliance to resolve inquiries into claims, authorizations, and eligibility.
- Establish and leverage relationships with contracted hospitals and providers to ensure the needs of the members are met and policies of the plan are followed.
- Utilize leadership skills and serves as a subject matter expert for clinical criteria, UM, hospital throughput and discharge planning issues and is a resource for AAH and community partners clinical and non clinical team members in expediting the resolution of outstanding issues.
- Identify system issues that result in failure to provide appropriate care to members or failure to meet service expectations and make recommendations for improvement Complete other duties and special projects as assigned.
- Timely assessment of inpatient admissions, bedside assessment and transitions of care and discharge planning of members.
- Evaluating clinical presentation against clinical guidelines and applicable regulatory requirements.
- Coordinating other care management activities.
- Writing, reporting, administration, and analysis.
- Communicating effectively, both verbally and in writing.
- After hours support required on a rotational basis.
- Traveling to hospitals and clinics as needed.
- Complying with organizations Code of Conduct, all regulatory and contractual requirements, organizational policies, procedures, and internal controls.
- Constant and close visual work at desk or computer.
- Constant sitting and working at desk.
- Constant data entry using keyboard and/or mouse.
- Frequent use of telephone headset.
- Frequent verbal and written communication with staff and other business associates by telephone, correspondence, or in person.
- Frequent lifting of folders and other objects weighing between 0 and 30 lbs.
- Frequent walking and standing
- Frequent driving of automobiles.
MINIMUM YEARS OF ADDITIONAL RELATED EXPERIENCE:
- Active California Registered Nurse License required.
- Bachelor’s degree strongly preferred.
SPECIAL QUALIFICATIONS (SKILLS, ABILITIES, LICENSE):
- Two years experience in managed care or health care setting preferred.
- Three years clinical experience required.
- Milliman Care Guidelines, (MCG), Managed Care and DHCS/NCQA experience preferred
- Excellent verbal and written communication skills.
- Ability to work within guidelines and protocols to achieve decisions independently.
- Excellent critical thinking and problem solving skills.
- Ability to work in cooperation with others.
- Ability to prioritize multiple projects as well as work with others.
- Working knowledge of managed care.
- Working knowledge of RVS, CPT ICD-9, ICD-10, and CPT 4.
- Ability to act as resource to department staff.
- Knowledge of DME and Home Health Services.
- Knowledge of ancillary and hospital based services.
- Current driver’s license, automobile insurance, and car registration required.
- Maintain continuous current nursing license required.
- Proficient experience in Windows including current Microsoft Office suite.
- Have a cleared TB test prior to or within seven days of hire.
- Current CPR and first aid card prior to or within six months of hire is preferred
$89,360 - $134,050
Alameda Alliance for Health is an EQUAL OPPORTUNITY EMPLOYER. Applicants and employees are considered for positions and are evaluated without regard to mental or physical disability, race, color, religion, gender, national origin, age, genetic information, military or veteran status, sexual orientation, marital status or any other protected Federal, State/Province or Local status unrelated to the performance of the work involved.