UM Review NurseAlohaCare is a local, non-profit health plan serving Hawai`i's low-income residents with free Medicaid and dual Medicare health insurance coverage. Our members include children, seniors and adults residing on all islands. We provide comprehensive benefits and managed care services with an emphasis on healthy living habits and preventive primary health care. Our approach is to meet the whole-person health and social needs of members. Through our community partnerships we offer innovative services such as connection to social service agencies, Native Hawaiian healing services and in-home primary care for qualified members. Our mission is to serve in the true spirit of aloha by ensuring and advocating for access to quality health care for all. We are Hawaii's third-largest health plan and offer a wide network of quality primary care, specialists, hospitals, pharmacies and among many other providers across the state. AlohaCare employees have a passion for helping Hawai`i's most underserved communities. Our caring culture is fundamental to our company-wide team approach to providing high quality services. We support our employees with 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 by recognizing outstanding job performance and collaboration. We share organization-wide updates during quarterly All Staff meetings. We encourage participation in volunteer and educational opportunities. We put a high value on honesty, respect, and trust-building. We encourage open-door, two-way, and frequent communication. AlohaCare's comprehensive benefits package includes low-cost medical, dental, drug and vision insurance, paid time-off, 401k employer contribution, referral bonus and pretax transportation and parking program. 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, compliance, 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 and Responsibilities:
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, readmission 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.
Welcome and participates in education and training activities.
Identifies opportunities to improve processes and communicates them to the Manager.
Participate in team coverage and scheduling.
Review 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 30-day readmissions.
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.
All other duties assigned.
Adhere to regulatory compliance and quality guidelines as well as AlohaCare policies and procedures.
Responsible for maintaining AlohaCare's confidential information in accordance with AlohaCare policies, and state and federal laws, rules, and regulations regarding confidentiality. Employees have access to AlohaCare.
Requirements:
Licensed RN or LPN in the State of Hawaii.
Minimum of 1 year of experience in Utilization Management or a minimum of 2 years of direct patient care experience in a hospital setting.
Ability to conduct training with audiovisual presentations.
Ability to use Utilization Management software, MCG Criteria, Microsoft Office, CPT and ICD-10 Manuals, AlohaCare Policy and Procedure.
Achieves results, builds trust, communicate effectively, customer and quality focused.
Strong interpersonal and facilitation skills with the ability to communicate with all levels of the organization.
Strong, effective, and precise written and oral communication skills; speak clearly and persuasively in positive or negative situations.
Professional telephonic etiquette skills.
Ability to solve problems, analyze, think critically and make good judgment.
Strong customer service skills and be able to work in a diverse, demanding and evolving environment with strong conflict and problem resolution skills.
Able to work independently with minimal supervision.
Able to effectively work in a fast-paced and changing environment, manage multiple projects and priorities across multiple teams/projects and in a matrixed environment.
Possesses excellent time management and organizational skills; is dependable, enthusiastic, self-starting, and self-motivated. Uses time effectively, reacts professionally under pressure.
Intermediate skills in Microsoft Programs: Word, Excel, Outlook and PowerPoin t.
Experience in the operation of general office equipment to include PC, fax/copy machine and phone system.
Preferred Requirements:
Minimum of 3 years of inpatient clinical experience.
State regulatory experience.
URAC/NCQA and HEDIS exposure.
Mental, Physical and Environmental Demands:
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.
In office working environment.
May require prolonged sitting- up to 4 hours.
Requires prolonged operation of a computer workstation, including the ability to type for extended periods of time on a keyboard during the scheduled workday.
Salary Range: $70,000 $85,000 annually
Temporary hire through December 15, 2026 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/veteran status, or other characteristics protected under applicable state and federal laws, regulations, and/or executive orders.
