Utilization Review Manager - Remote - Faulkner

Case Management Nurse

Site: Brigham and Women's Faulkner Hospital, Inc.

Mass General Brigham relies on a wide range of professionals, including doctors, nurses, business people, tech experts, researchers, and systems analysts to advance our mission. As a not-for-profit, we support patient care, research, teaching, and community service, striving to provide exceptional care. We believe that high-performing teams drive groundbreaking medical discoveries and invite all applicants to join us and experience what it means to be part of Mass General Brigham.

Job Summary

Schedule: Per Diem

Performs the six essential activities of Case Management: Assessment, Planning, Implementation, coordinating, monitoring, and Reassessing through the continuum of care to facilitate a safe, cost-effective transition post-discharge. Performs all aspects of audits and appeals, including the peer-to-peer process.

Perform utilization review to evaluate for the appropriate level of care and fax all insurance reviews timely to prevent denials.

Collaborates with appropriate individuals, departments, and payers to ensure appropriateness of admission, continued days of stay, and reimbursement.

Demonstrates working knowledge of different industry criteria sets like Milliman and InterQual.

Demonstrates in-depth understanding of all insurance plans, including Medicare, Medicaid, other entitlement programs, as well as commercial insurances and other types of plans: PPO, HMO, or indemnity.

Interact with various third-party payers on a daily basis. Fax clinical in payor communication to the right insurer with the right fax number in the right time frame.

Refer cases not meeting the appropriate level of care to the Physician Advisor or EHR.

Review for Observation status and make changes as needed. Accurately facilitate all documentation needed for Medicare status change from inpatient to observation (code 44).

Perform and monitor for quality issues and document in R.L. solutions.

Serves as a resource to staff and physicians for questions about the process of denial of care for Medicare, Medicaid or other insurances.

Reviews cases retrospectively when requested by the finance department to determine if admission relates to continued care for Medicare.

Must be able to function independently in busy environment.

Coordinate, complete, and track all clinical denials and appeals.

Communicates with the attending physician and care coordination nurse around notification of denial of care to gain understanding of the care needs of the patient.

Performs other duties as assigned-Complies with all policies and standards

Qualifications

• Bachelor's Degree in Nursing required
• Massachusetts Registered Nurse License required
• 5 years of Acute Care Nursing required
• 3 year of Utilization Review and Case Management experience preferred
• 4 or more years of Utilization Review and Case Management experience preferred
• 6 or more of Acute Care Nursing preferred

Knowledge, Skills and Abilities

• Staff adheres to all I C.A.R.E. Standards.
• Demonstrates knowledge, skills and abilities to work with various age groups in order to provide a safe discharge plan.
• Must be able to provide care for the patient despite psychosocial, educational, or physical disability.
• Basic computer skills, experience with Excel and Word, and good computation skills.
• Ability to interact and communicate within a diverse community.
• Competent with InterQual Criteria.
• Competent in Utilization Review, appeals, the peer-to-peer process, and Case Management.
• Use critical thinking skills in all interactions and recognize the need to be solution-driven.
• Good negotiating skills with insurance companies and third-party payers.
• Performs all aspects of discharge planning to the right environment of care, timely.
• Proficient in the use of ECare.

Additional Job Details (if applicable)

Remote Type

Remote

Work Location

1153 Centre Street

Scheduled Weekly Hours

0

Employee Type

Per Diem

Work Shift

Day (United States of America)

Pay Range

$41.36 - $100.00/Hourly

Grade

RN3500At Mass General Brigham, we believe in recognizing and rewarding the unique value each team member brings to our organization. Our approach to determining base pay is comprehensive, and any offer extended will take into account your skills, relevant experience if applicable, education, certifications and other essential factors. The base pay information provided offers an estimate based on the minimum job qualifications; however, it does not encompass all elements contributing to your total compensation package. In addition to competitive base pay, we offer comprehensive benefits, career advancement opportunities, differentials, premiums and bonuses as applicable and recognition programs designed to celebrate your contributions and support your professional growth. We invite you to apply, and our Talent Acquisition team will provide an overview of your potential compensation and benefits package.

EEO Statement:

2810 Brigham and Women's Faulkner Hospital, Inc. is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religious creed, national origin, sex, age, gender identity, disability, sexual orientation, military service, genetic information, and/or other status protected under law. We will ensure that all individuals with a disability are provided a reasonable accommodation to participate in the job application or interview process, to perform essential job functions, and to receive other benefits and privileges of employment. To ensure reasonable accommodation for individuals protected by Section 503 of the Rehabilitation Act of 1973, the Vietnam Veteran's Readjustment Act of 1974, and Title I of the Americans with Disabilities Act of 1990, applicants who require accommodation in the job application process may contact Human Resources at View phone number on click.appcast.io.