Utilization Review Manager - Home Care jobs in Honolulu, HI

Apply on line at http://www.alohacare.org/Careers/Default.aspx

The Company:

AlohaCare is a local, non-profit health plan serving the Medicaid and Medicare dual eligible population. We provide comprehensive managed care to qualifying health plan members through well-established partnerships with quality health care providers and community-governed health centers. Our mission is to serve individuals and communities in the true spirit of aloha by ensuring and advocating access to quality health care for all. This is accomplished with emphasis on prevention and primary care through community health centers that founded us and continue to guide us as well as with others that share our commitment. As Hawaii’s third-largest health plan, AlohaCare offers comprehensive prevention, primary and specialty care coverage in order to successfully build a healthy Hawaii.

The Culture:

AlohaCare employees share a passion for helping Hawaii’s most underserved communities. This passion for helping and caring for others is internalized and applied to our employees through a supportive and positive work environment, healthy work/life balance, continuous communication, and a generous benefits package.

AlohaCare’s leadership empowers and engages its employees through frequent diversity, recognition, community, and educational events and programs. AlohaCare has a strong commitment to support Hawaii’s families and reinforces a healthy work/home balance for its employees. Because AlohaCare values honesty, respect and trust with both our internal and external customers, we encourage open-door, two-way communication through daily interactions, employee events and quarterly all-staff meetings. AlohaCare’s comprehensive benefits package includes low cost medical, dental, drug and vision insurance, PTO program, 401k employer contribution, referral bonus and pretax transportation and parking program.

These employee-focused efforts contribute to a friendly, team-oriented culture which is positively reflected into the communities we serve.

The Opportunity:

Job Summary:

The primary responsibility of the UM Review Nurse is to conduct prior authorizations and concurrent reviews, using proprietary or online tools for medical necessity and documentation systems that integrate service requests, care management, and claims. The nurse will work collaboratively with the Medical Directors to implement medical policies and guidelines that are consistent with MedQUEST, Medicare, and NCQA requirements. The UM Review Nurse fosters a team culture of interdependency, efficient workflows, new learning, adaptability to change, critical thinking, compliancy, and professional provider communication. Cost-effective member access to clinical or health services is paramount in the UM Review Nurse’s daily activities. By behavior and work style, the UM Review Nurse communicates, coordinates, and collaborates with other AlohaCare staff or external parties that result in outstanding utilization management of members and their providers.

Primary Duties, Responsibilities and Competencies:

• Review referrals, member eligibility, benefit coverage, and member qualifications using AlohaCare’s criteria.
• Interface with Providers (physicians, DME, and other providers) to discuss issues and concerns with PA requests process and facilitate timely access to medically necessary health care services required by plan members.
• Perform medical necessity reviews for authorizations and retrospective requests and discuss possible denials with AlohaCare’s Medical Director.
• Process authorization decisions using AlohaCare’s care management system.
• Provide interdepartmental communication and referrals for members with Severe Mental Illness, Special Education Needs and Disabilities, Aid to Disabled Review Committee, and Case Management.
• Provide timely computer entry of encounter information/ data to maintain an accurate record of clinical reviews and the services authorized.
• Maintain the assigned workload within turnaround times in compliance with state and federal regulations.
• Concurrent reviews related to hospitalizations or post-acute care venues are completed with the intent to address appropriate levels of care and timely discharge planning.
• Perform concurrent clinical review via phone and by review of clinical documentation, to determine the appropriate length of a patient’s inpatient stay in accordance with all state and federal mandated regulations and AC policy and procedure.
• Participate in internal inpatient clinical rounds in collaboration with AlohaCare’s internal clinical teams and Medical Director to discuss the current admissions, discharges, and complex cases.
• Conduct a clinical review of claims and appeals and grievances in accordance with all state and federal mandated regulations and AC policy and procedure.
• Respond to telephone messages, e-mails, and other forms of communication in a timely and professional manner.
• Welcomes and participates in education and training activities.
• Identifies opportunities to improve processes and communicates them to the Manager.
• Participates in team coverage and scheduling.
• Other duties as assigned.
• Responsible to maintain AlohaCare’s confidential information in accordance with AlohaCare policies, and state and federal laws, rules, and regulations regarding confidentiality. Employees have access to AlohaCare.
• Position may include review of the following: Outpatient Prior Authorizations, Inpatient Authorizations, Long Term Care Authorizations, Home and Community Based Services Authorizations, Outpatient Behavioral Health Authorizations, Inpatient Behavioral Health Authorizations, and/or Aid to Disabled Review Committee (ADRC) reviews and submissions.

Job Qualifications & Requirements

• RN or LPN currently licensed in the State of Hawaii
• At least one-year experience in UM or at least 2 years of direct patient care experience in a hospital setting

Required Competencies and Qualifications:

• Ability to function independently and coordinate the work of other personnel effectively
• Must be able to work as a team
• Must exhibit strong clinical, planning, organizational and time management skills
• Basic computer knowledge
• Must possess excellent verbal and written communication skills.
• Must communicate with internal and external staff in a professional manner
• Learn and develop experience in the use of AlohaCare’s information system, proprietary screening tool, care management system, QNXT and, as necessary, AlohaCare’s historical databases
• Ability to conduct training with audiovisual presentations.

Preferred Qualifications

• Three years inpatient clinical experience preferred
• State regulatory experience preferred
• URAC/NCQA and HEDIS exposure an asset

Mental, Physical and Environmental Demands:

• Inside working conditions.
• No environmental hazards.
• Sedentary Work: Exerting up to 20 pounds of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects. Sedentary work involves sitting most of the time but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally, and all other sedentary criteria are met.

Salary range: $70,000 - $85,000 annually

AlohaCare is committed to providing equal employment opportunity to all applicants in accordance with sound practices and federal and state laws. Our policy prohibits discrimination and harassment because of race, color, religion, sex (including gender identity or expression), pregnancy, age, national origin, ancestry, marital status, arrest and court record, disability, genetic information, sexual orientation, domestic or sexual violence victim status, credit history, citizenship status, military/veterans status, or other characteristics protected under applicable state and federal laws, regulations, and/or executive orders.