Utilization Management Non Clinical Jobs in California

Position Summary:

Under the direct supervision of the Medical Director Resource Management, the PACE Resource Management, RN is responsible for all non-acute resource management and associated care coordination activities on a retrospective and on-going basis, reviewing claims for services and verifying the appropriateness of care. This position works directly with the PACE CMO or their designee, to evaluate and monitor medical appropriateness, determinations and care coordination activities. This position is responsible for developing an appropriate plan approved by the IDT and implementing resource management projects and interventions, which will have a direct impact on improved outcomes and cost containment for San Diego PACE participants.

Essential Functions of the Job:

• Performs retrospective reviews on all inpatient and facility services assessing for appropriateness and medical necessity of the treatment requests using nationally recognized guidelines (InterQual or other criteria adopted by San Diego PACE), tied in to claims.
• Performs prospective, initial, concurrent and retrospective reviews for medication utilization rates and costs, diagnostics/testing, referrals to specialists, durable medical equipment (DMEs), care giving hours and transportation utilization, assessing for appropriateness and medical necessity of the treatment requests using nationally recognized guidelines (InterQual or other criteria adopted by San Diego PACE)
• Assess care quality and clinical risk issues on a concurrent basis, reporting any recognized issues to the IDT, Quality Improvement Department, any other relevant teams and PACE CMO.
• Responsible for the proactive resource management of post-acute and chronically ill patients with the objective of improving quality outcomes and mitigating costs.
• In conjunction with the CMO, evaluates individual cases and provides feedback as needed to San Diego PACE PCP’s and their respective IDT regarding participants ALF and homecare plans and available covered services including identifying alternative levels of care that may be covered.
• With input from Transitions of Care RN Case Managers (TOC), addresses barriers to discharge/transition at team meetings including IDT and specific facility or specialty-based ones like SNF, ALF, Hospice.
• Participate proactively in identifying priority areas of resource management gaps, collect and analyze data, assist in determining root causes, all for the purpose of developing plans for solutions.
• Develops strong working relationships with outside contracted providers, PCP’s, IDT members, ensuring medically necessary and appropriate resource utilization.
• Coordinates an interdisciplinary approach to support continuity of care.
• Assess documentation of medical records for completeness and relationship to the treatment plan and identify gaps or barriers in treatment plans.
• Provides utilization management, and issuance of all appropriate authorizations for covered services as needed by members.
• Facilitate on-going communication between staff and contracted providers to ensure authorizations are secured in a timely and efficient process.
• Coordinates clinical utilization reviews and reporting of highest utilization cases.
• Actively participates in the discussion and notification processes that result from the clinical utilization reviews with the facilities and service providers.
• Works closely with Quality Department and follows up on complaints, grievances and quality issues related to participant post-acute or ALF level stays.
• Reviewing data and how predictive analytics may be emphasized to mitigate healthcare recidivism within 30 calendar days.
• Develop and monitor standard practices in care based on those who may benefit from a palliative-hospice platform due to disease trajectory and prognosis.
• Accountability for relevant Key Performance Indicator’s (KPI’s) for Resource Management, including but not limited to obtaining information from Transitions of Care RN Case Managers, to synthesize the following: utilization rates per 100 participants per month for Urgent Care (UC), Emergency Department (ED) visits, Acute Hospital Admissions and Acute/post-acute Skilled Nursing Facility (SNF) Admissions and length of stay in hospital and SNF’s.
• Review of current, retroactive, and future appropriateness of clinical and overall care, both internally for San Diego PACE and externally with approved vendor providers.
• Strong working knowledge of InterQual for direct use and for the education of IDT and clinical teams, including TOC Nursing Case Managers.
• Presentations on relevant topics and projects to PACE staff and external providers.

Additional Duties and Responsibilities:

• Works independently and as an effective member of the team.
• Multi-tasking for projects and their respective activities, timelines, and issues.
• Demonstrated ability to inter-relate with PCP’s, RN’s, medical assistants, internal departments, outside agencies, and the public.
• Demonstrated customer-focused service skills (internal and external customers).
• Demonstrated knowledge of PACE regulations related to eligibility requirements and plan specifics.
• Working knowledge of InterQual or other evidence-based care guidelines.
• Basic physical, psychosocial, and functional assessment skills.
• Able to collaborate between San Diego PACE and community resources.
• Thorough knowledge of appropriate resource utilization of acute hospital, long-term care, DME, palliative/hospice services and homecare resources.
• Able to document concise yet thorough clinical documentation.
• Demonstrated strong communication and customer service skills, problem solving, critical thinking, time management, organizational skills, and clinical judgment abilities.
• Familiarity and ability to use computers as well as EHR’s.
• Complies with all departmental, organizational, and government policies & procedures.
• Attends meetings and trainings as required.
• Adheres to and models SYHC’s core values and behaviors of Excellence, Empowerment, Integrity, and Respect.
• Performs other duties as assigned.

Job Requirements

Experience Required:

• Minimum of 3 years RN experience in an outpatient and/or hospital and/or PACE and/or resource utilization position
• Knowledge of PACE regulations (state and federal).
• Knowledge of principles and practices of health care service delivery, managed care, health care systems, and medical administration

Experience Preferred:

• 3 years or more of managed care experience including a year in resource utilization management, case management or care coordination
• At least 1 year working with the frail or elderly
• Strong analytical skills with ability to quickly evaluate clinical documentation and apply evidence-based criteria
• Project management skills
• Experience performing audits analyzing productivity and quality of utilization management.
• Knowledge and/or experience with the senior care market, including competitors, regulations, and available resources
• Experience with EPIC, Interqual and QuickCap

Education Required:

• Graduate of an accredited registered nursing program

Education Preferred:

• ASN/BSN preferred
• Certified Case Manager (CCM) or Certified Professional in HealthCare Management (CPHM)

Certifications Required:

• Current unencumbered CA RN License
• Current BLS and First Aid Certifications from American Heart Association

Equipment Used:

• EPIC EMR experience

Verbal and Written Skills Required to Perform the Job:

• Excellent oral, written, and interpersonal communication skills.

Technical Knowledge and Skills Required to Perform the Job:

• Must possess the skills to thrive in team environment, must possess good organizational and supervisory skills, and ability to effectively handle difficult and unusual interpersonal situations.
• Meet a standardized set of competencies for the specific position description established by San Diego PACE and approved by CMS.
• Microsoft Office experience

Universal Requirements

Pre employment requirements include I-9, physical, positive background and reference check results, complete application, new hire orientation, pre-employment PPDs.