Bienvivir All-Inclusive Senior Health (“Bienvivir”) is a community-based, patient-centered, comprehensive health care delivery system that advocates and promotes quality of life, optimum independence, dignity, and choices in a nurturing environment for frail seniors. Since 1987, Bienvivir has served the frail seniors of El Paso, Texas through the provision of the Program of All-Inclusive Care for the Elderly (“PACE”).

PACE is a unique managed care benefit for frail seniors (referred to as participants) age 55 and older who are certified by the state as needing nursing home level care and who reside in a PACE service area. PACE programs coordinate and provide comprehensive medical and support services so that participants can remain independent and stay in their homes for as long as safely possible.

BENEFITS for Full and Part-time employees who work 30 or more hours per week:

We pay 100% of the MEDICAL monthly premiums for Employee Only coverage.

We pay 100% of the DENTAL monthly premiums for Employee Only coverage.

We provide an affordable VISION monthly premium for Employee + Family coverage.

We pay 100% of BASIC LIFE for a benefit amount of $10,000.

We offer safe harbor matching contributions for the 403(B) RETIREMENT SAVINGS account.

We offer up to fifteen (15) days of PAID TIME OFF based on paid hours per pay period.

We offer eleven (11) company-observed PAID HOLIDAYS.

We offer education and TUITION REIMBURSEMENT.

We offer MILEAGE REIMBURSEMENT.

Bienvivir is currently accepting applications for the following position:

UTILIZATION MANAGEMENT NURSE RN

Under the direct supervision of the Quality Improvement Manager, and in collaboration with the Medical Director, the Utilization Management (UM) Nurse RN is responsible for overseeing the Utilization Management Program to include utilization review and management in acute care, sub- acute, long term acute care (LTAC), post-acute skilled care, and referrals to medical specialists. This role involves case review, data analysis, and proper documentation of services. This position leads the UM committee. Key responsibilities include managing communication processes with the provider networks and the Interdisciplinary Team, authorization of services related to participant service reviews and Participant preferences, and ensuring consistent and accurate documentation of services to support appropriate payment of service claims.

RESPONSIBILITIES:

1. Adheres to and enforces Bienvivir service authorization policies, ensuring that participant care and related claims are reasonable and necessary for diagnosis or treatment and consistent with PCP coordination decisions.

2. Monitors participant care and related claims to ensure they concur with accepted medical standards and are consistent with the participant care needs including level of care and advanced care planning principles.

3. Conducts concurrent reviews of all hospital admissions (observation and inpatient) and collaborates with the Interdisciplinary Team and the Discharge Coordinator RN to drive efficient and timely transitions of care.

4. Conducts retrospective reviews of inpatient admissions under 48 hours, and claims submitted inconsistent with the service authorization.

5. Conducts concurrent reviews of all acute, subacute, long-term acute (LTAC) and Skilled Nursing Facilities (SNF) admissions with the Interdisciplinary Team driving efficient and timely discharge plans and transitions of care. Provides authorization for SNF admissions and ensures all necessary care is provided to the participant while in skilled respite.

6. Coordinates and reviews all other services delivered by contracted providers. Assures provider consistency with Interdisciplinary Team service authorization, care plans, and PCP coordination decisions. Coordinates and reviews out-of-network providers as needed.

7. Effectively uses knowledge, critical thinking, and advocacy skills to advocate quality care, enhanced quality of life, and when appropriate, decreased hospital stays.

8. Maintains accurate and complete documentation of all patient-related interactions in the Electronic Medical Records (EMR).

9. Leads the provider appeals process for rejected claims, including comprehensive review of provider network appeals. Collaborates with the Medical Director to review and respond to appeal requests, ensuring issuance of a written determination consistent with the Bienvivir policies.

10. Monthly analyses KPI performance of acute care, post-acute care, emergency room utilization, admissions, readmissions to acute care within 30 days of discharge, and referrals to outpatient specialists.

11. Prepares quarterly utilization reports for committees such as the UM Committee, Committee with Community Input (CCI) and the Quality Improvement Committee.

12. Prepares and delivers a variety of Utilization Management (UM) reports to various departments, including executive leadership.

13. Oversees the Utilization Management (UM) Program, ensuring effective implementation and adherence to policies and procedures.

14. Leads the Utilization Management (UM) Committee, which is comprised of the Medical Director, the Director of Nursing, the Assistant Director of Nursing, the Pace Center Directors, the Vice President of Finance, the Discharge Coordinator, the Director of Pharmacy, the Coordinated Care Team, the Quality Improvement Data Analyst, the Home Health Director, the Quality Improvement Manager, the Quality Improvement Manager, and other staff as required.

15. Provides the UM committee with case reviews, analysis of utilization trends and identifies areas of over and under-utilization.

16. Leads and/or actively participates in process/quality improvement initiatives, working with a variety of departments and multi-disciplinary staff

17. Works collaboratively with Information Technology (IT) to improve data quality, design dashboards, and provide clinical context for utilization.

18. Other duties as assigned.

QUALIFICATIONS / REQUIREMENTS:

1. A graduate of an accredited nursing program with a license to practice in the state of Texas as a Registered Nurse.

2. Required one (1) to two (2) years of clinical experience.

3. Preferred case management or utilization management experience.

4. Preferred previous experience working in risk based integrated models of care.

Required Skills

Required Experience

• Experience with DAI and CERBERUS.
• Ability to use and manipulate Microsoft Office products, including but not limited to: Excel, Word, and MS Project.
• Knowledge and understanding of DoD financial management programs and policies
• Ability to work in a fast-paced environment

Desired:

• Prior experience with PIEE and Advana