PACE Utilization Manager RN (Central Valley PACE - Modesto)

Provides utilization management functions as a part of the Program for All Inclusive Care for the Elderly benefits management system. This includes providing utilization review and management for all acute, post-acute, and outpatient services as well as performing the identification, analysis and resolution of resource utilization outliers consistent with established protocols, policies and procedures. Serves as a liaison between network providers and the CV PACE clinical and Interdisciplinary Teams (IDT) related to participant assessment, care planning, and care coordination to assure participants progress toward desired outcomes with quality care that is medically appropriate and cost-effective based on the severity of illness and the site of service. Works closely with finance and claims adjudication teams for the purposes of care management, data analysis and practice, and system performance.

Schedule: Monday - Friday, 8:00am - 5:00pm.

Compensation:

$52.42 - $60.68 an hour.

Golden Valley Health Centers offers excellent benefits including Medical: (0 Deductible / $2,000 Individual; $4,000 Family Out-of-Pocket Max), excellent PPO coverages; Dental; Vision; 403(b) with match, FSA plans, gym discounts, and so much more!

Duties and Responsibilities

• Performs concurrent and retrospective utilization management reviews and functions; collect, analyze, and report outcomes to internal and external stakeholders.
• Responsible for the development, review, revision, and implementation of utilization management policies and protocols that ensure valid utilization review outcome measures.
• Collaborate with the PACE Medical Director, Health Plan Director, Director of Center Operations, Clinical Manager and PCPs ensuring all participant hospitalizations are authorized for the correct status (inpatient, outpatient short stay, observation status) consistent with the participant's severity of illness.
• Collaborate with the Medical Director, Health Plan Director, Director of Center Operations, Clinical Manager and center IDTs to ensure appropriate initial and ongoing service authorization for post-acute participant stays.
• For all level of care and service authorization decisions, communicates the information necessary to all stakeholders assuring appropriate claim adjudication and payment.
• Performs concurrent review process in order to effectively manage the length of inpatient and post-acute stays consistent with participant goals of care and care plan.
• Prepare succinct, written clinical case summaries that include rationale for the authorized service and payment status.
• Serve as a resource for CV PACE PCPs and network provider care managers to ensure consistent and accurate level of care and service authorization for appropriate claim submission and payment.
• Collaborate with the Medical Director, Director of center Operations, Clinical Manager and Health Plan Director to manage the provider claim denial appeal policy and process.
• Document all participant and staff interactions in the electronic medical record consistent policy;
• Maintains professional relationships with internal and external stakeholders, including provider community, while identifying opportunities for utilization management process improvement;
• Develop and implement strategic plans, which will have a direct impact on appropriate resources utilization and improved patient outcomes.
• Identify high-risk patients via inpatient rounds, provider referral patterns, utilization management referrals, and disease registry reporting mechanisms, and refer to appropriate PACE site medical leadership.
• Maintains up to date knowledge of PACE rules and regulations governing utilization management processes; implements approved policies, procedures and workflows.
• Ensures timely referral processing by tracking within the authorization system and coordinating with internal and external stakeholders for timely referral processing.
• Responsible for daily coverage needs for inpatient concurrent reviews, discharge planning, utilization management authorization request review, and ensures patients meet appropriate level of care based on acceptable evidence-based clinical criteria(s).
• Responsible for the oversight and coverage needs for daily review and processing of referral authorizations in accordance with turnaround time standards set by PACE regulations requirements.
• Alerts the IDT RN of noticed changes in participant's condition.
• Participates in IDT meeting's as necessary;
• Other duties as assigned

Physical Demands

• Requires standing, walking, occasional pushing, pulling, and lifting.
• Ability to lift up to 30 pounds. Moving or lifting greater than 30 pounds should be done with assistance as appropriate.
• Requires manual and finger dexterity and eye-hand coordination.
• Requires corrected vision and hearing to normal range, with or without reasonable accommodation.
• Must be able to communicate verbally with all staff, caregivers, participants, and community at large.
• Ability to interact professionally and respectfully with geriatric individuals including those with cognitive decline and/or physical frailties.
• Requires working under stressful conditions.
• Moderate pressure to meet scheduled appointments while dealing with frail and confused participants.
• Subject to participants that may have the potential for verbal or physical aggression.

Work Environment

• Exposure to biohazards, including infectious material and waste and any other conditions common in a health care environment.
• Subject to unpleasant odors
• The noise level is usually quiet to moderate, but may at times be noisy and crowded.

Education/Experience Requirements

Minimum Qualifications:

• Valid CA Driver's License, acceptable driving record, and vehicle insurance.
• Detailed-oriented and organized.
• Excellent written and verbal communication skills with specific ability to maintain accurate records.
• Excellent customer service skills.
• Must have integrity, practice discretion and practice objective problem solving.
• Ability to collect, organize, manage and report on large volumes of meaningful data for decision making while using spreadsheets or other data processing software.
• Knowledge of basic statistical principles.
• Skilled in establishing and maintaining effective working relationships with participants, coworkers, medical staff, and the public.
• Skilled in identifying and recommending problem resolution.
• Knowledge of safety and infection control requirements for healthcare facilities.
• Demonstrated experience in quality assurance and performance improvement activities.
• Proficient in Microsoft Office applications; advanced Microsoft Excel experience required.
• Knowledge of State and Federal healthcare regulations.
• Only act within the scope of authority to practice.
• Meet a standardized set of competencies for the specific position description established by Central Valley PACE and approved by CMS before working independently.

Education/Experience:

• Graduate of an accredited school of professional nursing.
• Current unencumbered CA Registered Nurse (RN) License.
• Current BLS CPR Card certified by American Heart Association.
• Practiced nursing within the last three (3) years.
• Minimum one (1) year experience working with the frail or elderly population.
• BSN highly preferred.
• Minimum of three (3) years of managed healthcare experience including one (1) or more years in at least one of the following areas: utilization management, case management, care transition and/or disease management required.
• Certified Case manager (CCM) or Certified Professional in Healthcare Management Certification (CPHM) preferred.