Montage Health’s application process has changed effective 12/20/2019.
If you submitted an online application prior to 12/20/2019, you will be required to recreate your profile information if you want to apply to any new positions. You will no longer have access to your previously saved profiles and applications. Current employees applying for transfer into a posted position must also create a profile.
As a Utilization Management Nurse at Aspire Health Plan, you will make sure our health services are administered efficiently and effectively. You will assess and interpret member needs and identify solutions that will help our members live healthier lives. The central goal of this position is to provide operational support and clinical expertise in the areas of health care services, member benefits and clinical operations for all AHP members to improve member and provider satisfaction as well as quality of care and health outcomes.
The Utilization Review Nurse will:
Determine the appropriateness of inpatient and outpatient services following the evaluation of medical guidelines and benefit determinations
Identify and report any quality of care concerns that occur while members are in acute care and/or SNF facilities.
Support AHPs compliance to regulatory and accreditation requirements for both state and federal agencies.
Support quality audits, chart audits, and reviews of medical records as needed for either complex high cost cases or cases with quality of care concerns..
Coordinate case management on complex cases that require additional clinical management support.
Conducts initial review of prior authorization or pre certification requests for determination of coverage for members covered by sponsored health benefit plans.
Makes determinations based on medical necessity of plan-covered services based on internal policies reviewed and approved by the Medical Director of the plan. Where appropriate, involves the Medical Director if a partial or fully adverse medical necessity determination is expected based on the initial review.
Works collaboratively with the Director of HCS to achieve all UM targets monthly.
Participates in and supports all medical management initiatives including, but not limited to: ER visits, re admissions, OOA utilization and identification of potential high cost cases.
Collaborates with care managers on care transitions for patients with an emphasis on high risk patients at risk for readmission, as needed
Accountability and Dependability: Assumes responsibility for accomplishing duties in an effective and timely manner.
Integrity: Consistently honors commitments and takes responsibility for actions and words.
Software and Computer Skills: Proficient in the use of Microsoft Office Suite, Highly skilled at using the Internet .Must learn effectively with computer-based and/or online training.
Flexibility: Demonstrates adaptability and openness to alternative solutions and flexibility when interacting with others, understanding their attitudes, needs, interests, and perspectives.
Active unrestricted RN license required in state of residence
Working knowledge of Milliman Criteria
3-5 years’ experience working in a managed care environment with Medicare Advantage and Commercial populations
Pre-authorization and Concurrent review experience
Utilization Management experience
Support business hours of 8 to 5:00, Monday-Friday PST
Strong computer skills
Aspire Health Plan is a locally owned Medicare Advantage HMO that provides comprehensive medical coverage to seniors and other Medicare recipients in Monterey County. We’re proud to be a community-centered organization backed by Community Hospital of the Monterey Peninsula and Salinas Valley Memorial Hospital. Over 700 doctors, many other healthcare providers, and all four Monterey County hospitals are part of the Aspire Health Plan network. It’s the care you need from people you know.
Aspire Health is an equal opportunity employer.
*All Telecommuters will be required to adhere to Aspire Health Plan’s Telecommuter policy
Assigned Work Hours:
40 Hours Monday through Friday