AIDS Healthcare Foundation

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Utilization Management Registered Nurse - Temporary

Utilization Management Registered Nurse - Temporary

Req No 
2017-6129
Job Locations 
US-CA-Los Angeles
Category 
Managed Care
Type 
Temporary Full-Time

More information about this job

WHO WE ARE

AMAZING INDIVIDUALS WORKING FOR POSITIVE PEOPLE at AIDS Healthcare Foundation!

 

Does the idea of doing something that really makes a difference in people’s lives while being well-compensated intrigue you? Are you looking to work for an organization that encourages growth and success from each and every one of its employees?

 

If so, AIDS Healthcare Foundation is the place for you!

 

Founded in 1987, AIDS Healthcare Foundation is the largest specialized provider of HIV/AIDS medical care in the nation. Our mission is to provide cutting edge medicine and advocacy, regardless of ability to pay. Through our healthcare centers, pharmacies, health plan, research and other activities, AHF provides access to the latest HIV treatments for all who need them.

  

AHF’s core values are to be:

 

• Patient-Centered

• Value Employees

• Respect for Diversity

• Nimble

• Fight for What’s Right

 

 

STILL INTERESTED? Please continue!

 

AIDS Healthcare Foundation is seeking a Temporary, Full-Time, Utilization Management Registered Nurse (Temporary UMRN) to assist our Managed Care Division located at the following address:

 

1001 North Martel Avenue

Los Angeles, California 90046

 

Hours of Operations: 

Monday - Friday, 8:30am-5:30pm

YOUR CONTRIBUTION TO OUR SUCCESS!

The Utilization Management Registered Nurse (UMRN) is responsible for projecting and integrating the Mission and Core Values of the organization in the provision of utilization management services to members and medical providers of AIDS Healthcare Foundation’s Medicare Health Plan, MediCal Health Plan and where designated, Ryan White Programs.

 

Key responsibilities of the UMRN include but are not limited to:

  1. Making decisions as to the level of care necessary and appropriate for the patients, whether to approve or present for modification or denial to the Medical Director specific admissions to acute or skilled facilities, modes of inpatient or outpatient treatment, diagnostic testing or medications. Such decisions may cover the health plan members as well as uninsured or underinsured patients within the AHF managed care environment. 
  2. To reduce fragmented care and readmissions by coordinating the patient, patient care givers, inpatient discharge team and next level of care transitioning interdisciplinary team needed to implement the patient-centered transition from the acute or skilled nursing facility to the next level of care after an episode of illness or medical intervention.
  3. Applying professional, national, contractual, regulatory, and Plan standards to utilization management decisions on a consistent and non-biased patient centered manner.

 

Essential Duties & Responsibilities

Includes the following: 

 

  • Maintaining current knowledge and proficiency in Medicare and MediCal utilization management guidance, regulations and contractual requirements as they relate to prior authorization/coverage determinations, redeterminations, exception processes and appeals. 
  • Performs pre-admission, concurrent inpatient and retrospective reviews to determine whether or not an admission is, or remains to be, reasonable and medically necessary using Medicare, MediCal, InterQual and/or AHF Best Practice criteria and guidance. 
  • Requests clinical information within 24 hours of notification of an inpatient admission.
  • Demonstrated ability in utilizing relationship management, coordination of services, resource management education, patient advocacy, and other related interventions to:
    • Assure the receipt of timely information related to utilization management is received from hospitals, nursing facilities, medical providers and other health care entities.
    • Promote improved quality of care and/or life.
    • Promote cost effective medical outcomes.
    • Prevent hospitalization/readmission when possible and appropriate.
    • Prevent complications in patients by assuring discharge planning and transition of care continuity is in place and implemented for all members.
    • Assure medically indicated and appropriate levels of care are received by members.
    • Identify quality of care issues.

 

  • Performs case reviews in a timely manner and notifies providers of determination within 72 hours of clinical decision. 
  • Reviews PHC acute care admissions for medical necessity.  Reviews initial and continuing care PHC acute care Treatment Authorization Request (TAR) against information provided during concurrent review for accuracy and approves or refers case to Medical Director for denial or administrative day conversions.  Documents all rationale for decision making in appropriate software system and the TAR prior to submission to MediCal.  
  • Will assist with the transition from partial to full risk for the MediCal HMO plan product line, including admission and concurrent review along with discharge planning and coordination efforts with facility and care management staff.   Will participate in the updating and drafting of policies to reflect operational shifts in accordance to this transition.
  • Collaboration with the Primary Care Provider and/or attending physician, Transition of Care RN and other appropriate case managers and team members both internal and external, along with any additional  appropriate health care team members to facilitate the care transition,  care coordination, member and care giver education, continuity of the care plan and patient centered interventions.
  • Assists in the discharge planning process with both internal and external case managers/ discharge planners to assure the transition of care is effective and complete. Will place significant focus on providing the Transition of Care Staff with most up to date discharge information so that the staff may facilitate scheduling of post discharge visits within 7 days with either the member’s PCP or the Health Plan Nurse Practitioner
  • Concurrent Review and collaboration with case managers at the acute care setting, skilled nursing facilities, acute rehabilitation units, long term care facilities and hospice care.  Obtains appropriate facility assessment or certification documents as required by each level of care and incorporates into the utilization management plan for the individual patient, e.g. National Coverage Determinations, MDS SNF Evaluation, Hospice Certification/Recertification, etc. 
  • Maintenance of current Medicare and MediCal regulation and requirement knowledge for:
    • Skilled nursing pre-admission evaluation, admission evaluation, continued skilled stay necessity review.
    • Long term care admission evaluation, interval assessment and continued stay requirements.
    • Organizational determinations, reconsiderations, expedited reviews, Independent Review Entity (IRE) reconsiderations, QIO review of coverage terminations, appeals, etc.
    • Hospice benefit initial certification and benefit period certification, levels of hospice services and coordination of Medicare/MediCal non-hospice services where necessary. 
  • Assesses each acute hospital admission to determine the appropriate level of care, i.e., critical care, telemetry, step down, medical-surgical, administrative, etc.
  • Assess each SNF or LTAC transition of care for appropriate admission and concurrent review criteria. 
  • Performs on-site review for acute and/or SNF member admissions, as needed.
  • Identifies and reports variances to the Manager of Utilization and Case Management.
  • Coordinates closely with the Plan’s Medical Director, referring cases that do not meet established criteria, Medicare, MediCal or Ryan White contractual requirements.
  • Reviews and make decisions on Prior Authorization request.  Documents decision process in UM systems.
  • Notifies UM Manager and Director of Claims when hospital acquired conditions or any denial of payment situations occur.
  • Perform retrospective claims review on admissions the Plan was not informed of or which require additional clinical review for indications and appropriateness of services.  Documents all findings in UM system.
  • Maintain accurate documentation of all reviews, interventions, clinical activities and communications.  Maintains organized patient files. 
  • Present comprehensive and up to date inpatient case information at the weekly case round meeting.

 

Generate bimonthly in-depth utilization review reports of members admitted for more      

than 10 days.   Cases will be presented for second level review by the Medical Director,

Director of Care Coordination and Manager of Care Coordination.  

 

  • Maintains current knowledge of MCO benefit structure, policies and procedures related to authorization of services. And is adept at creating a wrap around solution to address member’s needs using appropriate MCO benefits and available ASO and community resources.
  • As an RN serves as a clinical resource to Utilization Management authorization coordinators.
  • Completes a minimum of three recommended AIDS related in-services, trainings or conferences per year.
    • Obtains and maintains HIV/AIDS disease/treatment general knowledge proficiency. 
  • Prepares and distributes a daily inpatient report to Medical Director, Chief of Managed Care, Director of UM/CM and UM/CM Manager and appropriate AHF staff as indicated 
  • Other duties as assigned.

Participation in AHF Meetings/Committees

  • Participate in weekly Utilization/Case Management rounds.
  • Monthly Department Meeting
  • Utilization Management Committee
  • Monthly Managed Care Staff Meeting
  • Attends other AHF meetings as assigned.

 

Supervisory Responsibilities

In the absence of both the Director and Manager of the Care Coordination department, the UR Nurse may be called upon to provide clinical and daily operational leadership.