Gender Affirming Services UM Nurse

Amida Care is a Diversity, Equity, and Inclusion employer committed to full
inclusion and elimination of discrimination in all its forms. We strive to
develop, promote, and sustain a culture that values equity and leverages
diversity and inclusiveness in all that we do.

This position is responsible for completing utilization management (UM) for
all gender affirming services (GAS) requests. Following all regulatory
guidelines and timeframes, the GAS UM Nurse will review and process all
requests for GAS.

ESSENTIAL FUNCTIONS
Essential functions are job duties and responsibilities that must be
performed to accomplish the purpose/ goals of the job.

•       Coordinate, in conjunction with Clinical Services, Utilization Management
(UM) determinations in accordance with Article 49-Utilization Review.

•       Ensure UM is completed by following all regulatory guidelines and
timeframes

•       Document all UM activities in the appropriate database

•       Work with Amida Care provider network to ensure current clinical
guidelines are widely distributed

•       Educate providers regarding Plan benefits, UM policies, and clinical
criteria

•       Ensure pre and post-surgery care coordination is member driven and
supports increased health outcomes.

•       Educate members and providers regarding Plan benefits, policies, and
support services available to members

•       Perform regular cases reviews and member rounds in accordance with Amida
Care’s Model of Care.

•       Engage members and providers when a need is identified that will support
improved health outcomes for the behavioral and physical health of members of
transgender experience.

•       Conduct aftercare follow-up calls to providers to ensure/track member
adherence with appointments post-discharge and record information in the
appropriate electronic database.

•       Review clinical documentation, claims/utilization data to ensure members
are receiving appropriate care and implement strategies to address unmet
needs as appropriate.

•       Conduct needs assessments to determine appropriate referrals and
supports.

MINIMUM JOB REQUIREMENTS

•       Registered Nurse

•       Two (2) years’ utilization management experience in a health plan
setting, required

•       Knowledge of transgender surgical procedures, preferred

•       Two (2) years’ health care or managed care experience, preferred

•       Two (2) years’ experience working with the transgender community,
preferred

•       Bilingual (English/Spanish) preferred

•       Strong knowledge of Microsoft Office (Access, Word and Excel).

•       Demonstrate understanding and sensitivity to multi-cultural values,
beliefs, and attitudes of both internal and external contacts.

•       Demonstrate appropriate behaviors in accordance with the organization’s
vision, mission, and values.