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:
· 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.
· 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.
· Applying professional, national, contractual, regulatory, and Plan standards to utilization management decisions on a consistent and non-biased patient centered manner.
· 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.
Education and/or Experience:
· Graduate from an accredited RN Program.
· 3 or more years of acute hospital experience with adults in medical/surgical, critical care or ER
· HIV/AIDS nursing experience desired.
· 2 or more years of recent Utilization Review/Case Management experience required.
· Medicare and MediCal Utilization Management knowledge.
· Managed Care experience a plus.
Certification and Licenses:
· Must have California RN License (without restrictions)
· Current California RN License.
· Current Driver’s License with proof of liability insurance.
· CPUR, CPUM or CPHM within 15 months of employment.
We offer competitive salary commensurate with experience, benefits, bonus incentives and an amazing work environment.
Submit a recent copy of your CV to Cristina.firstname.lastname@example.org or call (323) 337-9148.
Visit our website at www.aidshealth.org