Utilization Review is the process in which medical review determinations are made based on clinical guidelines and structured processes. This position reviews the utilization of the organization/plan’s resources against established criteria, monitors and evaluates the medical necessity, appropriateness and efficient use of health care services.
The UM/Transition of Care RN is responsible for projecting and integrating the Mission and Core Values of the organization in the provision of care management services to members of the AHF/AHFMCO Medicare and Medicaid health plans of Florida.
Key responsibilities include leading the transition of care process, providing culturally and linguistically sensitive care management services to the HIV/AIDS special needs population enrolled in the Medicare and Medicaid health plans under the supervision of the Utilization Manager, participating in the gathering and transmission of information and data to the RN Care Team Manager for assessment, re-assessment and care planning, participating in interdisciplinary team meetings, participation in activities that increase understanding of the communities served by the AHF/AHF MCO and going the extra mile to assure members have access and knowledge of their health plan benefits, community benefits, treatment plan, and medication adherence.
Duties and Responsibilities include but are not limited to:
• The Transition of Care UM Nurse is responsible for projecting and integrating the Mission and Core Values of the organization within and outside of the Managed Care Department.
• Collaborates with transitioning facility staff to assure discharge planning and physician discharge orders have been implemented and confirmed as executed prior to the patient’s discharge
• Concurrent acute care, sub-acute, hospice, transitional care & long term care to determine whether or not an admission is, or remains to be, reasonable and medically necessary, using established criteria, e.g., InterQual, Medicare or Medicaid, or AHF Best Practice criteria
• Collaborates with the Primary Care Provider and/or attending physician, internal and external case managers, patient and/or family and other healthcare providers to provide continuity and quality of care in the most cost effective manner
• Assists in the discharge planning process with both internal and external case managers/discharge planners and/or patient and family.
• Concurrent Review and collaboration with internal case managers of all acute care, skilled nursing, acute rehabilitation, long term care, hospice and home with home care services admissions of Plan members.
• Provides feedback related to each acute care hospital admission to determine the appropriate level of care, i.e., critical care, telemetry, step down, medical-surgical, administrative, etc.
• Collaborates with and plays a lead role to re-engage the member during and following a medical, rehabilitation and behavioral inpatient admission through reassessment, coordination of transition of care, including PCP appointment, supplies, services and transportation as needed
• Provides transition of care visits in the inpatient setting to educate the patient, when consented to by the patient, the family/significant other on their discharge plan, i.e., what to expect, medications prescribed, what they were prescribed for and how to take them, reconciling pre and post hospitalization medication lists, keeping personal health record/notes and what and when to report symptoms to the UM/TOC nurse, RNCTM or PCP, as well as conducting follow-up home/ transition facility visits and calls to patients following the transition to a new level of care to assure plan is progressing and PCP visit has occurred.
• Intercedes directly on member behalf when necessary to assure smooth transition process, e.g., assuring delivery of prescription medications, authorizing care/services based upon indications and appropriateness of care criteria, substituting home health vendors when care or supply commitments for transition are not met, etc.
• Collaborates with the Health Care Center and external network PCPs, the Care Team and other practitioners to ensure members are well supported and managed within the Health Home of the Chronic Care Model.
• Collaborates with ASO's, PAC Providers and other Community Services as necessary to ensure appropriate access to service and follow up on the results to such referrals.
• Completes assessments and re-assessments timely for members as needed during transition of care, updates RNCTM on assessment findings, discharge plan and changes to patient individual care plan.
• With the member, establishes and updates patient centered long term and short term goals for care and self-management.
• With the input of the member, family and medical team, creates an appropriate and timely individual and updates care plan to assist the member to achieve the established goals.
• Maintains current knowledge of MCO benefit structure, policies and procedures related to authorization of services. And is adept at creating a wraparound solution to address member’s needs using appropriate MCO benefits and available ASO and community resources.
• Works to deliver care management services in an efficient and cost effective manner.
• Communicates the care plan to the Primary Care Physician, member and others in the Health Home.
• Revises the Care Plan following hospitalization of the member or following the annual re-assessment.
• Meets with patients face to face in the home or at physician appointments to complete transition of care assessments, surveys and other contacts, as necessary.
• Provides health education regarding disease process, medications, medication adherence, community resources and benefits.
• Collaborates with AIDS Service Organizations and other community resources, as necessary, to ensure appropriate access to care and services.
• Maintains current clinical knowledge of HIV/AIDS medications and treatment regimens.
• Maintains at least the minimum performance and productivity standards.
• Completes a minimum of three recommended AIDS related in-services, trainings or one conference per year.
o Obtains and maintains HIV/AIDS disease/treatment general knowledge proficiency
• Reports urgent member issues and barriers to care to the Primary Care Provider and the Director of UM/CM, as appropriate.
• Advocates for member needs with medical provider, RN Care Team Manager and community.
• Reports all complaints and grievances per grievance policy.
• Prepares or assists in preparing weekly, monthly, quarterly and yearly and ad hoc utilization review reports as directed by UM Manager.
• Other duties as assigned to ensure team goals are met.
Collaborates with the Director of UM/CM or their designee on the day to day supervision of the Care Team members.
Organizes and leads the team conferences with the Interdisciplinary Team.
Collaborates with the Plan Medical Director, Manager and Director of Utilization and Case Management regarding member clinical, satisfaction, utilization and cost issues.
To perform this job successfully, an individual must be able to satisfactorily perform the essential duties. 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
Graduate from an accredited RN program required
BS in Nursing preferred
At least five years clinical experience and three years Case Management, Community nursing, Home Health or Hospice nursing desired
Managed Care experience a plus with knowledge of Medicare and Florida Medicaid regulations
Certified Case Manager (CCM) or eligible for certification with one year of employment.
Certified in AIDS Care or eligible for ANAC certification within one year of employment
Computer/Software Skills & Abilities
To perform this job successfully, an individual should have adequate typing skills and basic knowledge of business software, including but not limited to: MS Word MS Excel, MS Access data base input to pre-designed forms, Internet Explorer and MS Outlook. Knowledge of MS Visio a plus.
Excellent written and verbal communication skills.
Ability to read, analyze, and interpret AHF/AHF MCO documents, policies, procedures, publications, and other documents.
Ability to respond effectively to sensitive inquiries or issues
Skilled in motivational interviewing techniques to engage member in the plan of care
Ability to effectively present information and respond to questions from groups of peers, superiors, clients, customers, and the general public.
Bilingual Spanish, and/or Creole a plus.
Ability to define problems, collect data, establish facts, and draw valid conclusions. and express same verbally and/or in writing..
Ability to interpret and follow a flow diagram.
Ability to apply the nursing process to assessment, care planning and patient management.
Ability to prioritize tasks and delegate to the appropriate staff
Ability to interpret a variety of technical instructions in mathematical or diagram format including abstract and concrete variables.
Over 80% Local travel. Home/ field based position with daily local travel to Health Care Centers, inpatient facilities, physician offices, patient homes, other health venues and AHF offices.
Other Skills & Abilities/Qualifications
Excellent organizational skills.
Ability to successfully work and communicate effectively with various levels of professional (e.g., physicians, professional nurses, licensed psycho-social professionals, licensed healthcare professionals health care administrators, etc.) and non-professional staff/external individuals (non-licensed allied health personnel, lay case managers, care coordinators, family/significant others, etc.).
Ability to successfully mediate conflicts between individuals or groups
Must be able to work independently and as a leader or member of a team.
Knowledge of HIV/AIDS, related medical and patient care issues and concerns in diverse populations
Certificates, Licenses and Registrations
Unrestricted Registered Nurse licensed by the State of Florida
Baccalaureate Degree preferred
Certification in case management preferred
Valid Florida Driver’s License with proof of automobile liability insurance
We at AIDS Healthcare Foundation believe that each individual is entitled to equal employment opportunities without regard to race, color, creed, gender, sexual orientation, gender identity, marital status, national origin, age, veteran status or disability. The right of equal employment opportunity extends to recruiting, hiring selection, transfer, promotion, training and all other conditions of employment.