RN, Utilization Management Grievance & Appeal

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 and future increases will be based on the pay band for the city and state you reside in.

POSITION SUMMARY

Under the direction of the Manager, Utilization Management (UM), the RN, Utilization Management Grievance & Appeal, will review requests for medical services against National Clinical Guidelines. The RN, Utilization Management Grievance & Appeal, uses judgment in selecting appropriate guidelines and in applying general policies and procedures. 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 and discharge planning for post-acute settings. Responsible for screening enrollees for initiatives and programs including Case Management, Enhanced Care Management and California Children’s Services (CCS). The RN, Utilization Management Grievance & Appeal will be assigned to one of the following functional areas: Prior Authorization, Concurrent Stay Review, Discharge Planning or Grievance and Appeals. 

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

•    Review precertification requests for medical necessity, referring to the Medical Director those that require additional expertise. (Prior authorization assignment).

•    Review clinical information for concurrent reviews, extending the Length of Stay for inpatients as appropriate. (Concurrent stay review assignment)

•    Assist hospital staff in facilitating timely discharges to home and/or other levels of care. (Discharge Planning assignment) 

•    Proactively identify members whose physical, mental and social circumstances present a barrier to safe hospital discharge. 

•    Review member grievances and determine classification as clinical or administrative. (Grievance and appeals assignment)

•    Ensure appeals, grievances and provider dispute reconsiderations are resolved timely to meet regulatory timeframes. (Grievance and appeals assignment)

•    Assist hospital staff in facilitating timely discharges to home and/or other levels of care.

•    Establish effective rapport with other employees, professional support service staff, customers, clients, patients, families, and physicians.

•    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.

•    Provide appropriate referrals to Case Management.

•    Identify appropriate alternative and non-traditional resources and demonstrate creativity in managing each case to fully utilize all available resources.

•    Maintain accurate records of all interventions.

•    Performs utilization review for all members requiring services requiring authorization.

•    Conducts assessment of medical necessity utilizing MCG online criteria.

•    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.

•    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.

•    Participates in clinical joint operation meetings with facilities/providers as needed.

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: Nursing, Healthcare, Case Management

Experience: Case management and/or utilization review experience preferred.

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

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

Other Requirements:

•    The principles and practices of utilization management. Effectively apply acute care medical/surgical nursing practices. Use clinical guidelines for medical necessity determinations.

•    Demonstrated ability to problem-solve complex, multifaceted, emotionally charged situations. Ability to successfully manage conflict, negotiating “win-win” solutions.

•    Strong organizational, task prioritization and delegation skills. Patient advocacy focus.

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