UM Nurse Specialist

Location: Orange, California US

Notice

This position is no longer open.

Job Number: 1642

Workplace Type:

Position Title: Utilization Review Nurse

External Description:

Summary:

 

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:

 

  1. 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
  1. Handles escalated cases either internally or those referred by a contracted providers.
  2. Assures network integrity by evaluating network effectiveness and communication cross-functionally as appropriate.
  3. 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.
  4. Tracks and reports statistics as requested;
  5. Manage the UM Dashboard for specific market, ensuring timely submission to the Director of Utilization Management;
  6. Ensures compliance with the NOMNC/DENC processes when SNF, HHA, or CORF services
  7. Working closely with Clinical Educator to develop the training material for UM staff.
  8. Ensuring that the Clinical staff are utilizing Alignment Health Care-approved Clinical Criteria.
  9. Ensuring that all staff are using CMS approved letter templates when communicating UM decisions / actions to members.
  10. Ensuring that all staff are using CMS/Alignment Health Care approved language in Member communication.
  11. Ensuring that all staff are managing and transferring members according to the Continuity of Care requirements.
  12. Ensuring that all staff are documentation is in compliance with internal processes as outlined in Department policies, protocols and standard operating procedures.
  13. Collecting, evaluating and reporting data and activities as applicable within the UM Monthly Reports, NOMNC, OMT, Medical Services Committee Reports (MSC))
  14. Maintains confidentiality of information between and among health care professionals.
  15. Other duties as requested or assigned.

 

Supervisory Responsibilities

May include supervision of some the UM Coordinator(s) and nurse(s), as applicable to market.

 

Qualifications

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.

 

  1. Education and/or Experience: Successful completion of an accredited Registered Nursing Program; two to three years related experience in a managed care setting
  2. Certificates, Licenses, Registrations: Current, Active and Unrestricted Registered Nursing License
  3. Other Qualifications:
  4. Knowledge of Medicare Managed Care Plans
  5. Computer Skills: Word, Excel, Microsoft Outlook
  6. Experience with the application of UM Criteria (i.e., Milliman Care Guidelines, Apollo, CMS National and Local Coverage Determinations, etc.)
  7. 3+ years of utilization management/quality improvement experience
  8. Working knowledge and understanding of quality improvement concepts
  9. Previous experience as a lead in a functional area or managing cross functional teams on large scale projects

Skills and Abilities

  1. Language Skills: Effective written and oral communication skills; ability to establish and maintain a constructive relationship with diverse members, management, employees and vendors;
  2. Mathematical Skills: Ability to perform mathematical calculations and calculate simple statistics correctly
  3. 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;
  4. Problem-Solving Skills: Effective problem solving, organizational and time management skills and ability
  5. Report Analysis Skills: Comprehend and analyze statistical reports.

 

Physical Demands

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.

 

  1. 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.
  2. The employee is frequently required to reach with hands and arms.
  3. The employee is occasionally required to climb or balance and stoop, or kneel.
  4. The employee must occasionally lift and/or move up to 20 pounds.
  5. Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, depth perception and ability to adjust focus.

 

Working Environment

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.

  1. The noise level in the work environment is usually moderate.

 

Reports To: Director of UM

City: Orange

State: California

Location City: Orange

Location State: California

Community / Marketing Title: UM Nurse Specialist

Company Profile:

By leveraging our world-class technology platform, innovative care delivery models, deep physician partnerships and our serving heart culture, Alignment Health is revolutionizing health care for seniors! From member experience professionals and clinicians, to data scientists and operations leaders, we have built a talented and passionate team that is deeply committed to our mission of transforming health care for the seniors we serve. Ready to join us?

At Alignment, delivering exceptional care to seniors starts with ensuring an exceptional experience for our over 1,300 employees. At the center of our employee experience is a culture where employees at all levels and across all teams are encouraged to share their unique ideas and perspectives. After all, when you can bring your authentic self to work, whether that’s in a clinical setting, our corporate office or a home office, creativity and innovation flourish! Another important part of the Alignment culture is a belief in continuous learning and growth. As a result, in this fast-growing company, you will find ample support to grow your skills and your career – with us.

EEO Employer Verbiage:

 

Please note: All clinical positions are contingent upon successful engagement with Alignment Health’s COVID-19 Vaccination program (fully vaccinated with documented proof or approved exception/deferral).

Alignment Health is an Equal Opportunity/Affirmative Action Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, age, protected veteran status, gender identity, or sexual orientation.

*DISCLAIMER: Please beware of recruitment phishing scams affecting Alignment Health and other employers where individuals receive fraudulent employment-related offers in exchange for money or other sensitive personal information. Please be advised that Alignment Health and its subsidiaries will never ask you for a credit card, send you a check, or ask you for any type of payment as part of consideration for employment with our company. If you feel that you have been the victim of a scam such as this, please report the incident to the Federal Trade Commission at https://reportfraud.ftc.gov/#/. If you would like to verify the legitimacy of an email sent by or on behalf of Alignment Health’s talent acquisition team, please email [email protected].