RN, Utilization Management II

Gold Coast Health Plan will not sponsor applicants for work visas.

The pay range above represents the minimum and maximum rate for this position in California. Factors that may be used to determine where newly hired employees will be placed in the pay range include the employee specific skills and qualifications, relevant years of experience and comparison to other employees already in this role. Most often, a newly hired employee will be placed below the midpoint of the range. Salary range will vary for remote positions outside of California.

POSITION SUMMARY

Under the direction of the department manager, the Utilization Management (UM) RN II will review requests for medical services against National Clinical Guidelines. The UMRN II is responsible for assuring the receipt of high quality, cost-efficient medical outcomes for those enrollees identified as having the need for inpatient and/or outpatient authorization. This position will serve as a subject matter expert to the HS nursing staff. The UM RN II will be responsible for identifying staff developmental needs and assisting with auditing and training.

Work Schedule: Travel; work protracted and irregular hours and evening meetings or work unusual hours for meeting attendance or participation in specific projects or programs.

Amount of Travel Required:  30-50%

ESSENTIAL FUNCTIONS

Reasonable Accommodations Statement

To accomplish this job successfully, an individual must be able to perform, with or without reasonable accommodation, each essential function satisfactorily. Reasonable accommodations may be made to help enable qualified individuals with disabilities to perform the essential functions.

Essential Functions Statements

•    Mastery of Utilization Management RN I job skills

•    Performs utilization review for all members requiring services that require authorization. Demonstrated competency in two of the four utilization review areas:

     -    Prior Authorization

     -    Concurrent Stay Review

     -    Discharge Planning

     -    Provider Dispute Reconsiderations (PDR)/Clinical Appeals /Grievances 

•    Conducts assessment of medical necessity utilizing MCG online criteria and Gold Coast Health Plan Medical Policies and Guidelines.

•    Gathers all pertinent information from providers and facilities to ensure GCHP physician reviewers have sufficient information to make a decision to approve or deny services.

•    Consistently meets/exceeds UM production standards

•    Maintains a 90% pass rate on quality audits

•    Coordinates with non-clinical staff to ensure all documentation is completed timely and in a professional manner.

•    Interfaces with internal resources including Medical Directors and other Health Services staff to ensure members receive the right care at the right time in the right setting by the right provider.

•    Use effective relationship management, coordination of services, resource management, education, patient advocacy, and related interventions to:

     -    promote improved quality of care and/or life

     -    promote cost effective medical outcomes    

     -    prevent hospitalization when possible and appropriate

     -    promote decreased lengths of hospital stays when appropriate

     -    prevent complications in patients under our care when possible

     -    provide for continuity of care

     -    assure appropriate levels of care are received by patients

•    Actively participates in team meetings

•    Demonstrated ability to develop Utilization Management Job Aid Manuals 

•    Independently identifies the need for development or change in department processes to improve department efficiency and efficacy

•    Serves as a SME to co-workers

•    Participates in peer audit activities 

•    Assists department lead and manager with other duties as assigned

•    May telework but required to come into office to precept/cross train staff

POSITION QUALIFICATIONS 

Competency Statements

•    Management Skills - Ability to organize and direct oneself and effectively supervise others.

•    Decision Making - Ability to make critical decisions while following company procedures.

•    Responsible - Ability to be held accountable or answerable for one’s conduct.

•    Customer Oriented - Ability to take care of the customers’ needs while following company procedures.

•    Problem Solving - Ability to find a solution for or to deal proactively with work-related problems.

•    Time Management - Ability to utilize the available time to organize and complete work within given deadlines.

•    Diversity Oriented - Ability to work effectively with people regardless of their age, gender, race, ethnicity, religion, or job type.

SKILLS & ABILITIES

Education:

•    Bachelor's Degree (four-year college or technical school) - Preferred

•    Field of Study in health-related field and managed care experience - Desired

Experience:    

•    2 plus years of experience in the health care field. Required. 

•    Case management and/or utilization review experience preferred. 

•    Managed care experience in a health plan, preferred.

Certifications & Licenses: RN, California Board Certified Registered Nurse License - Required

Computer Skills: Knowledge of basic computer applications with ability to adapt to new software programs.

SKILLS, KNOWLEDGE & ABILITIES:

Desired:

An attitude to excel, a special empathy for working with multiple populations, an investigative personality and a willingness to mentor colleagues.

A working knowledge of Medi-Cal and related policy and regulations.

Required:

•    Knowledge of Utilization management principles.

•    Knowledge of plan benefits, carve-outs and delegated services.

•    Knowledge of GCHP provider network and services provided by contracted physicians and facilities.

•    Knowledge of required regulatory timelines to ensure department compliance with State contracts.

•    Ability to successfully manage conflict, negotiating “win-win” solutions.

•    Demonstrated ability to problem-solve complex, multifaceted, emotionally charged situations.

•    Excellent communication and people skills.

•    Strong organizational and task prioritization skills.

•    Knowledge of basic computer applications with ability to adapt to new software programs.

•    Excellent typing skills

•    Strong writing skills.