UM Nurse Specialist
Location: Orange, California US
Job Number: 1357
Position Title: UM Nurse
The Utilization Management Nurse Specialist, under the direction of the Director of Utilization Management, performs the direct supervision of specific markets including overseeing all UM processes for that market. The UM Nurse Specialists is responsible for the day-to-day utilization management of both inpatient and outpatient cases, while promoting quality patient care outcomes through appropriate utilization/resource management along the continuum of care.
Essential Duties and Responsibilities
Essential duties and responsibilities include, but are not limited to:
- Ensure timely ongoing authorization requests review in all Alignment HealthCare markets.
- Ensure appropriate usage of resources in order to facilitate the UM process
- Ensure compliance within applicable state program guidelines
- Evaluate compliance policies and procedures and analyze/recommend enhancements
- Assist with ensuring consistent data collection from UM staff that is used to assist the company in achieving corporate goals, to improve monitoring and reporting in order to meet external requirements
- Identify opportunities for process improvements necessary to facilitate market operations and growth.
- Educate market-affiliated staff as necessary to ensure consistent performance and adhere to standards
- Handles escalated cases either internally or those referred by a contracted providers.
- Assures network integrity by evaluating network effectiveness and communication cross-functionally as appropriate.
- Works closely with Member Services Director and Patient Outreach Team Director and tracks continuity of care issues identified through the enrollment process, and resolves when identified.
- Tracks and reports statistics as requested;
- Manage the UM Dashboard for specific market, ensuring timely submission to the Director of Utilization Management;
- Ensures compliance with the NOMNC/DENC processes when SNF, HHA, or CORF services
- Working closely with Clinical Educator to develop the training material for UM staff.
- Ensuring that the Clinical staff are utilizing Alignment Health Care-approved Clinical Criteria.
- Ensuring that all staff are using CMS approved letter templates when communicating UM decisions / actions to members.
- Ensuring that all staff are using CMS/Alignment Health Care approved language in Member communication.
- Ensuring that all staff are managing and transferring members according to the Continuity of Care requirements.
- Ensuring that all staff are documentation is in compliance with internal processes as outlined in Department policies, protocols and standard operating procedures.
- Collecting, evaluating and reporting data and activities as applicable within the UM Monthly Reports, NOMNC, OMT, Medical Services Committee Reports (MSC))
- Maintains confidentiality of information between and among health care professionals.
- Other duties as requested or assigned.
May include supervision of some the UM Coordinator(s) and nurse(s), as applicable to market.
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
- Education and/or Experience: Successful completion of an accredited Registered Nursing Program; two to three years related experience in a managed care setting
- Certificates, Licenses, Registrations: Current, Active and Unrestricted Registered Nursing License
- Other Qualifications:
- Knowledge of Medicare Managed Care Plans
- Computer Skills: Word, Excel, Microsoft Outlook
- Experience with the application of UM Criteria (i.e., Milliman Care Guidelines, Apollo, CMS National and Local Coverage Determinations, etc.)
- 3+ years of utilization management/quality improvement experience
- Working knowledge and understanding of quality improvement concepts
- Previous experience as a lead in a functional area or managing cross functional teams on large scale projects
Skills and Abilities
- Language Skills: Effective written and oral communication skills; ability to establish and maintain a constructive relationship with diverse members, management, employees and vendors;
- Mathematical Skills: Ability to perform mathematical calculations and calculate simple statistics correctly
- Reasoning Skills: Ability to prioritize multiple tasks; advanced problem-solving; ability to use advanced reasoning to define problems, collect data, establish facts, draw valid conclusions, and design, implement and manage appropriate resolution;
- Problem-Solving Skills: Effective problem solving, organizational and time management skills and ability
- Report Analysis Skills: Comprehend and analyze statistical reports.
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
- While performing the duties of this job, the employee is regularly required to sit; use hands to finger, handle, or feel and talk or hear.
- The employee is frequently required to reach with hands and arms.
- The employee is occasionally required to climb or balance and stoop, or kneel.
- The employee must occasionally lift and/or move up to 20 pounds.
- Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, depth perception and ability to adjust focus.
The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
- The noise level in the work environment is usually moderate.
Reports To: Director of UM
Location City: Orange
Location State: California
Community / Marketing Title: UM Nurse Specialist
Who is Alignment Healthcare?
- Socially responsible
- Technologically enabled
- Concierge care
- Servant leadership
We are dedicated to transforming the complex and confusing process of medical treatment in the United States so that every link in the health care continuum becomes more efficient, productive, and effective. We built a team of people who want to make a difference. Come join the team that is changing health care one person at a time.
We believe that great work comes from people who are inspired to be their best. We invite you to explore our wide variety of roles based on your unique experience.
EEO Employer Verbiage:
Alignment Healthcare, LLC is proud to practice Equal Employment Opportunity and Affirmative Action. We are looking for diversity in qualified candidates for employment: Minority/Female/Disable/Protected Veteran.
If you require any reasonable accommodation under the Americans with Disabilities Act (ADA) in completing the online application, interviewing, completing any pre-employment testing or otherwise participating in the employee selection process, please contact firstname.lastname@example.org.